Other·August 14, 2018

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 the investigation of one complaint. Complaint number CA00475608. Representing the California Department of Public Health: Surveyor number 32191, HFEN The inspection was limited to the specific complaint and does not represent the findings of a full inspection of the facility. Three deficiencies were issued for complaint number CA00475608.

F157 SS=D NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC) CFR(s): 483.10(b)(11)

F157 05/09/2018 A facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications); a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or a decision to transfer 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: OMVU11 Facility ID: CA240000095 If continuation sheet 1 of 17 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 05/09/2018 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 discharge the resident from the facility as specified in §483.12(a). The facility must also promptly notify the resident and, if known, the resident's legal representative or interested family member when there is a change in room or roommate assignment as specified in §483.15(e)(2); or a change in resident rights under Federal or State law or regulations as specified in paragraph (b)(1) of this section. The facility must record and periodically update the address and phone number of the resident's legal representative or interested family member. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to notify the physician regarding one (Resident A) of three sampled residents' multiple episodes of diarrhea (loose, watery bowel movement). This failure to notify Resident A's physician resulted in delayed interventions which subsequently caused Resident A's admission to the acute hospital with severe dehydration (fluid intake fails to match fluid loss which can result in low blood pressure, high heart rate, and in severe cases lead to kidney failure and/or death), emergency surgery to remove her entire colon (large intestine), and death related to Resident A's septic shock (the body's inflammatory reaction to infection) secondary to severe Clostridium difficile (bacteria that causes diarrhea and other serious intestinal conditions). Findings: On February 12, 2016, at 11:35 a.m., an unannounced visit to the facility was conducted FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OMVU11 Facility ID: CA240000095 If continuation sheet 2 of 17 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 05/09/2018 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 to investigate a complaint related to infection control issues. On February 12, 2016, Resident A's record was reviewed. Resident A was admitted to the facility on January 27, 2016, with diagnoses which included hypertension (high blood pressure) and muscle weakness. Resident A's nursing note dated January 27, 2016, did not indicate gastrointestinal symptoms on admission. Resident A's occupational therapy note dated February 4, 2016, indicated Resident A had diarrhea since the day before (February 3, 2016). The document indicated Resident A had increased confusion during therapy session). The occupational therapy note indicated a nurse was informed regarding Resident A's diarrhea. Resident A's physical therapy notes were reviewed and indicated the following: a. February 4, 2016, Resident A had complaints of diarrhea, and a nurse was notified; b. February 5, 2016, Resident A had been having diarrhea for the past 3 days. The document further indicated Resident A having increased fatigue and was very impulsive. There was no documented evidence Resident A's episodes of diarrhea as reported by the occupational and physical therapists were reported to Resident A's physician on February 3, 4, and 5, 2016. The facility document titled, "Bowel Movement (BM) Clinical Record," dated February 1 to 7, 2016, was reviewed and indicated: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OMVU11 Facility ID: CA240000095 If continuation sheet 3 of 17 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 05/09/2018 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 a. February 1, 2016, Resident A had one large bowel movement; b. February 2, 2016, Resident A had no bowel movement; c. February 3, 2016, Resident A had one small bowel movement; d. February 4, 2016, Resident A had four bowel movement (more frequent compared to the past three days); The document indicated Resident A's bowel movement had a loose consistency. e. February 5, 2016, Resident A had two bowel movement in one shift; f. February 6, 2016, Resident A had one bowel movement; and g. February 7, 2016, Resident A had two bowel movements. There was no documented evidence Resident A's change in consistency and frequency of bowel movement on February 4, 2016, was assessed and reported to the physician. On February 29, 2016, at 2 p.m., a telephone interview was conducted with Resident A's family member. She stated Resident A had multiple loose stools on February 3, 2016. Resident A's family member stated she had asked a nurse to call the physician. She further stated the nurse did not notify the physician, and Resident A's diarrhea continued and worsened. On March 3, 2016, at 12:30 p.m., Resident A's facility physician was interviewed. He stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OMVU11 Facility ID: CA240000095 If continuation sheet 4 of 17 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 05/09/2018 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 Resident A's family member informed him of the resident's (Resident A) diarrhea on February 5, 2016. The facility physician stated he held the order to discharge Resident A to home and ordered stool for C-diff (detects harmful substances produced by the bacterium Clostridium difficile). He further stated the facility did not inform him of Resident A's episodes of diarrhea. Resident A's nursing notes dated February 8, 2016, indicated Resident A's family member requested that the resident to be transferred to an acute hospital due to weakness and for further evaluation. Resident A's hospital records were reviewed and indicated the following: a. February 8, 2016, history and physical at the acute emergency department, " ...Patient with h/o (history of) HTN (hypertension- high blood pressure) presents with 5 days history of abdominal pain, diarrhea, and abdominal distention...BUN (24 H) (blood urea nitrogen- to detect the health of the kidneys) normal - 7-18, Creatinine (2.230 H) (measures kidney function) normal was 0.550-1.020) ...WBC (20.8 H) normal was 4.8-10.8 ...Impression: Severe diffuse colitis (inflammation of the large intestine) and proctitis (inflammation of the rectum) ..." ; b. February 9, 2016, Resident A went into respiratory and kidney failure with impending septic shock; c. February 10, 2016, Resident A had emergency surgery for total colectomy (removal of the large intestine) due to toxic mega colon (rare, life-threatening widening of the large intestine and is usually a complication of inflammatory bowel disease). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OMVU11 Facility ID: CA240000095 If continuation sheet 5 of 17 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 05/09/2018 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 Resident A remained in the intensive care unit and received and required treatment from pulmonary, infectious diseases, and cardiology physicians throughout the hospital stay. Resident A's discharge summary from the acute hospital February 25, 2016 (22 days after the family first informed the facility that Resident A was having episodes of diarrhea), indicated Resident A, had expired (passed away) on February 25, 2016. The document further indicated, "Cause of Death: Septic shock secondary to severe Clostridium difficile colitis ...toxic ...acute kidney disease (happens when the kidneys suddenly lose the ability to eliminate excess salts, fluids, and waste materials from the blood) ..." A copy of Resident A's death Certificate was obtained on February 13, 2018, and listed the causes of death as septic shock, healthcare facility acquired pneumonia, and clostridium difficile colitis. The facility policy and procedure was reviewed. The undated policy and procedure titled," Clostridium Difficile," indicated," ...to inform doctor if patient has three or more episodes of loose stools ...Consider Clostridium difficile as caused of diarrhea, especially in the elderly, those with tube feeding, those who had received antibiotics or anti-neoplastic within the past two (2) weeks ..." The policy titled, "Policy/Procedure- Nursing Administration," revised May 2007, indicated," ...It is the policy of this facility that all changes in resident condition will be communicated to the physician and or NP (Nurse Practitioner) ...All symptoms and unusual signs will be communicated to the physician promptly. Routine changes are minor change in physical FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OMVU11 Facility ID: CA240000095 If continuation sheet 6 of 17 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 05/09/2018 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 and mental behavior ...The nurse in charge is responsible for notification of physician prior to end of assigned shift when a significant change in resident's condition is noted ..."

F309 SS=G PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING CFR(s): 483.25

F309 05/09/2018 Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OMVU11 Facility ID: CA240000095 If continuation sheet 7 of 17 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 05/09/2018 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 Based on interview and record review, the facility failed to promptly assess and provide interventions for one (Resident A) of three sampled residents' complaint of multiple episodes of diarrhea (loose, watery bowel movements). This failure resulted in delayed treatment which caused Resident A to be admitted to the acute care hospital with severe dehydration (fluid intake fails to match fluid loss which could lead to kidney failure and/or death) caused by the diarrhea, emergency surgery to remove the resident's entire large intestine, septic shock (complication of an infection with low blood pressure and inadequate blood flow to the organs) and death secondary to severe Clostridium difficile (C. diff - a species of bacteria that can cause symptoms ranging from loose, watery bowel movements, lifethreatening inflammation and swelling of the colon or large intestine, up to death). Findings: On February 12, 2016, at 11:35 a.m., an unannounced visit to the facility was conducted to investigate a complaint related to quality of care and infection control concerns. On February 12, 2016, Resident A's record was reviewed. Resident A was admitted to the facility on January 27, 2016, with diagnoses which included muscle weakness and post (after) high fever from unknown cause. Resident A's physician orders on admission indicated: a. January 27, 2016, levofloxacin (medication for infection) 750 mg (milligram)/150 ml intravenously (IV-administered into the vein) one time a day every two days until January FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OMVU11 Facility ID: CA240000095 If continuation sheet 8 of 17 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 05/09/2018 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 31, 2016, for gram positive cocci (bacteria); and b. January 27, 2016, vancomycin (medication for infection) 250 mg IV one time a day for positive gram cocci (bacteria causing infection). Resident A's nursing note dated January 27, 2016, indicated Resident A was admitted for IV antibiotic therapy and PT (physical therapy)/OT (occupational therapy) services. The document did not indicate any abnormal gastrointestinal issues or symptoms on admission. Resident A's occupational therapy note dated February 4, 2016, indicated Resident A had diarrhea since the day of February 3, 2016. The document indicated Resident A had increased confusion during therapy session. The occupational therapy note indicated a nurse was informed regarding Resident A's diarrhea. Resident A's physical therapy notes were reviewed and indicated the following: a. February 4, 2016, Resident A had complaints of diarrhea, and a nurse was notified; b. February 5, 2016, Resident A had been having diarrhea for the past 3 days. The document further indicated Resident A was having increased fatigue and was very impulsive. There was no documented evidence Resident A's episodes of diarrhea as reported by PT and OT staff were assessed on February 3, 4, 5, 2016. There was no evidence any interventions were initiated until February 5, 2016. The facility documentation of Resident A's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OMVU11 Facility ID: CA240000095 If continuation sheet 9 of 17 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 05/09/2018 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 bowel movements dated February 1 to 7, 2016, was reviewed and indicated: a. February 1, 2016, Resident A had one large bowel movement; b. February 2, 2016, Resident A had no bowel movement; c. February 3, 2016, Resident A had one small bowel movement; d. February 4, 2016, Resident A had four bowel movement (more frequent compared to past three days); The document indicated Resident A's bowel movement had a loose consistency. e. February 5, 2016, Resident A had two bowel movements; f. February 6, 2016, Resident A had one bowel movement; and g. February 7, 2016, Resident A had two bowel movements. There was no documented evidence Resident A's change in frequency and consistency of bowel movement on February 4, 2016, was assessed. Resident A's physician order dated February 5, 2016 (2 days after diarrhea was initially reported), indicated laboratory orders for a CBC (complete blood count- used to diagnose infection), BMP (basic metabolic panel- blood test to check on fluid balance and electrolytes)), and stool for C-diff (detects the presence of Clostridium difficile). The physician order further indicated, "Call me (physician) report soon. (Sic)" FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OMVU11 Facility ID: CA240000095 If continuation sheet 10 of 17 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 05/09/2018 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 Resident A's CBC, BMP and stool for C-diff were not collected until February 7, 2016. (two days after physician had ordered the tests and four days after diarrhea was initially reported). Resident A's laboratory work-ups were reviewed and indicated: a. February 8, 2016, (completed) WBC (white blood cells- diagnose presence of infection) was 11.17 (high) normal was between 4-10; b. February 8, 2016, (completed) C-difficile toxin was positive. Resident A's nursing note dated February 8, 2016, (five days after the diarrhea started) indicated Resident A was started on vancomycin 250 mg oral (by mouth) every 6 hours x 2 (times two) weeks regimen due to positive c-diff. On February 29, 2016, at 2 p.m., a telephone interview was conducted with Resident A's family member. She stated Resident A had multiple loose stools on February 3, 2016. Resident A's family member stated she had asked a nurse to call the physician. She further stated the nurse did not notify the physician, and Resident A's diarrhea continued and worsened. Resident A's family member stated the facility did not do anything until February 5, 2016. She stated the laboratory work-ups and the specimen (stool) were not collected until February 7, 2016. On March 3, 2016, at 12:30 p.m., Resident A's facility physician was interviewed. He stated Resident A's family member informed him of the resident's (Resident A) diarrhea on February 5, 2016. The facility physician stated he held the discharge order to home he had FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OMVU11 Facility ID: CA240000095 If continuation sheet 11 of 17 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 05/09/2018 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 already written for February 5, 2016, and ordered a stool specimen for C-difficile. He further stated the facility did not inform him of Resident A's episodes of diarrhea. The physician stated the facility should have collected the stool specimen for him to identify what caused the diarrhea so he could start the treatment. On March 24, 2016, at 9:06 a.m., Certified Nursing Assistant (CNA) 1 (worked on February 2 and 3, 2016, according to staffing schedule) was interviewed. She stated Resident A had loose stools three to four times on her shift (morning shift). CNA 1 stated she reported the issue to a licensed nurse. On March 24, 2016, at 10:09 a.m., a Restorative Nurse Assistant (RNA) who worked on February 4, 2016, according to staffing schedule, was interviewed. He stated Resident A had three to four time loose stools on February 4, 2016. The RNA stated he reported the BM (bowel movement) status of Resident A to a charge nurse on February 4, 2016. There was no evidence the episodes of loose stools on February 2, 3, and 4, 2016, were clearly documented in Resident A's record. There was no evidence these episodes of loose stools reported by the CNA 1 on February 2, and 3, 2016, and the RNA on February 4, 2016, were acknowledged, and assessed by any licensed nurse. Resident A's nursing notes dated February 8, 2016, at 14:39 (2:39 p.m.) indicated Resident A had a 4 lbs. (pound) weight loss in a week. The note further documented Resident A was "weak and unable to consume adequate meal intake due to recent diarrhea episode." Resident A's nursing notes dated February 8, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OMVU11 Facility ID: CA240000095 If continuation sheet 12 of 17 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 05/09/2018 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 2016, at 15:38 (3:38 p.m.) indicated Resident A's family member requested that the resident be transferred to an acute hospital, "d/t (due to) weakness," and for further evaluation. On March 24, 2016, the facility's policy and procedure, Clostridium Difficile undated, was reviewed. The policy read: "The policy of this facility is to inform the doctor if patient has three or more episodes of loose stools. This facility will provide guidelines for the care of residents with Clostridium difficile, verified by culture or by evidence of positive cytotoxin assay (testing for toxins), and to prevent transmission of Clostridium difficile to others." The policy further documented, "Diarrhea 1. Consider Clostridium difficile as cause of diarrhea, especially in the elderly, those with tube feeding, those who have received antibiotics or anti-neoplastics (chemotherapy) within the past two (2) weeks, and those who have had Clostridium difficile." Resident A's hospital records were reviewed and indicated the following: a. February 8, 2016, history and physical at the acute emergency department, " ...Patient with h/o (history of) HTN (hypertension- high blood pressure) presents with 5 days history of abdominal pain, diarrhea, and abdominal distention...BUN (24 H) (blood urea nitrogen- to detect health of kidney; normal - 7-18), Creatinine (2.230 H) (measures kidney function; normal - 0.550-1.020) ...WBC (20.8 H up from 11.17 on February 7, 2016, test; normal - 4.8-10.8 ...Impression: Severe diffuse colitis and proctitis (inflammation of the rectum) ..." b. February 9, 2016, Resident A went into respiratory and kidney failure with impending septic shock; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OMVU11 Facility ID: CA240000095 If continuation sheet 13 of 17 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 05/09/2018 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 c. February 10, 2016, Resident A had emergency surgery for total colectomy (removal of the entire large intestine) due to toxic mega colon (a rare, life-threatening widening of the large intestine and is usually a complication of inflammatory bowel disease). Resident A remained in the intensive care unit after surgery until she died on February 25, 2016. She required and received treatment from pulmonary, infectious diseases, and cardiology physicians throughout the hospital stay. Resident A's discharge summary from the acute hospital February 25, 2016 (22 days after the family informed the facility that Resident A was having episodes of diarrhea), indicated Resident A, had expired (passed away) on February 25, 2016. The document further indicated, "Cause of Death: Septic shock secondary to severe Clostridium difficile colitis ...toxic ...acute kidney disease (happens when the kidneys suddenly lose the ability to eliminate excess salts, fluids, and waste materials from the blood) ..." A copy of Resident A's death Certificate was obtained on February 13, 2018, and listed the causes of death as SEPTIC SHOCK, HEALTHCARE FACILITY ACQUIRED PNEUMONIA, and CLOSTRIDIUM DIFFICILE COLITIS.

F504 SS=D LAB SVCS ONLY WHEN ORDERED BY PHYSICIAN CFR(s): 483.75(j)(2)(i)

F504 05/09/2018 The facility must provide or obtain laboratory services only when ordered by the attending physician. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OMVU11 Facility ID: CA240000095 If continuation sheet 14 of 17 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 05/09/2018 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 This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to ensure laboratory testing was performed timely as ordered by the physician for one (Resident A) of three sampled residents. This failure resulted in delayed identification of a gastrointestinal infection which affected the provision of treatment causing further decline in Resident A's health status. Findings: On February 12, 2016, at 11:35 a.m., an unannounced visit to the facility was conducted to investigate a complaint related to infection control issues. On February 12, 2016, Resident A's record was reviewed. Resident A was admitted to the facility on January 27, 2016, with diagnoses which included muscle weakness and post (after) high fever of unknown cause. On February 5, 2016, Resident A's physician wrote an order to "Hold D/C (discharge) today, CBC (complete blood count- assist in diagnosing infection) and BMP (basic metabolic panel- measures fluid balance and electrolytes in the blood) today, to get stool (bowel movement specimen) for C. diff (Clostridium difficile - a species of bacteria that can cause symptoms ranging from loose, watery bowel movements, life-threatening inflammation and swelling of the colon or large intestine, up to death).) ...Call me report soon." The facility laboratory requisition for Resident A's laboratory work-ups (CBC, BMP, and stool for C..diff) dated February 5, 2016, was documented as collected and drawn on February 7, 2016 (2 days after physician FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OMVU11 Facility ID: CA240000095 If continuation sheet 15 of 17 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 05/09/2018 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 ordered the laboratory work-ups). There was no documented evidence the physician was notified of the delay even when the physician order dated February 5, 2016, indicated for the laboratory work-up to be done "today" (February 5, 2016). No evidence could be located in the facility record that indicated the physician's order had been verified to clarify "today." On February 17, 2016, at 4:28 p.m., an interview was conducted with the Director of Nursing (DON), in regards to Resident A's laboratory tests (CBC, BMP, and C. diff report) ordered but not done timely as ordered by the physician. The DON stated laboratory test were not done due to the weekend. The DON further stated if the laboratory order was "stat (immediately)" it would be done right away. On February 29, 2016, at 2 p.m., Resident A's family member was interviewed. She stated Resident A had diarrhea since February 3, 2016. Resident A's family member stated the facility was unable to obtain enough specimen (referring to the stool specimen) on Friday (February 5, 2016). She stated the laboratory did not pick the stool specimen on Saturday (February 6, 2016), then on Sunday (February 7, 2016, two days after the physician had ordered the labs) all laboratory work-ups (CBC, BMP, and stool specimen) were collected and drawn. Resident A's family member stated the laboratory results were not reported to the facility until February 8, 2016 (3 days after the physician ordered the tests). She stated they requested that Resident A to be sent to the acute hospital as soon as the laboratory result came back positive with C. diff. On March 3, 2016, at 12:30 p.m., Resident A's facility physician was interviewed. He stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OMVU11 Facility ID: CA240000095 If continuation sheet 16 of 17 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 05/09/2018 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 Resident A's family member informed him of resident's (Resident A) diarrhea on February 5, 2016. The facility physician stated he held the discharge order to home and ordered stool for C-difficile. He further stated the facility did not inform him of Resident A's episodes of diarrhea. The physician stated the facility should have collected the stool specimen for him to identify the cause of the diarrhea so he could start treatment. Resident A's nursing note dated February 8, 2016 (5 days after the diarrhea started) indicated Resident A was started on vancomycin (medication for infection) 250 mg oral (by mouth) every 6 hours for two weeks due to positive C-difficile. The facility policy and procedure was reviewed. The policy titled, "Diagnostic Tests," revised May 2007, indicated," ...It is the policy of this facility to provide the highest quality care to the residents. Physician ordered labs will be handled in a proficient manner to ensure timeliness, accuracy, and proper follow-up ..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OMVU11 Facility ID: CA240000095 If continuation sheet 17 of 17