Other·February 6, 2019

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 annual recertification survey conducted from October 15, 2018, through October 19, 2018. Representing the California Department of Public Health: Surveyor 32192, HFEN; and Surveyor 36779, HFEN. The facility census was 33 residents. The sample size was 14 residents.

F578 SS=E Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir CFR(s): 483.10(c)(6)(8)(g)(12)(i)-(v)

F578 11/09/2018 §483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. §483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate. §483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the 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: 312H11 Facility ID: CA240000095 If continuation sheet 1 of 32 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 10/19/2018 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's option, formulate an advance directive. (ii) This includes a written description of the facility's policies to implement advance directives and applicable State law. (iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. (iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law. (v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time. This REQUIREMENT is not met as evidenced by: 4. On October 18, 2018, at 2:30 p.m., Resident 10's record was reviewed. The record indicated Resident 10 was admitted to the facility on August 20, 2018, with diagnoses including end stage renal (kidney) disease with dependence on dialysis (a medical process that substitutes for the normal function of the kidney), cancer of the kidney and colon, gastrointestinal (pertaining to the stomach and/or intestines) hemorrhage (bleeding), and gangrene (death and decomposition of body tissue). Resident 10's POLST indicated he did not have an advance directive. There was no documented evidence Resident 10 was provided written information about an advance directive. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 312H11 Facility ID: CA240000095 If continuation sheet 2 of 32 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 10/19/2018 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 5. On October 16, 2018, at 3:00 p.m., Resident 33's record was reviewed. Resident 33's was admitted to the facility on December 27, 2017, with diagnoses including end stage renal disease with dependence on dialysis. Resident 33's POLST, dated December 27, 2017, indicated, "...No Advance Directive..." There was no documented evidence the facility provided Resident 33 with written information about an advance directive. 6. On October 16, 2018, at 4:00 p.m., Resident 31's record was reviewed. Resident 31's POLST, dated September 22, 2018, indicated, "...No Advance Directive..." There was no documented evidence the facility provided Resident 31 with written information about an advance directive. On October 16, 2018, at 4:10 p.m., an interview and review of the records of Residents 10, 31 and 33, were conducted with the SS. The SS stated the facility was supposed to give information on advance directives to the resident/resident representative at the time of admission. The SS stated it was usually given within three days after admission, but it may be within seven days which was when her social services assessment was due. The SS stated there was no documentation indicating written information regarding advance directives was given to Residents 10, 31 and 33. The SS stated Residents 10, 31 and 33, should have been provided written information on advance directives. The facility policy and procedure titled, "Advance Directives," dated November 2016, was reviewed. The policy indicated, "...It is the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 312H11 Facility ID: CA240000095 If continuation sheet 3 of 32 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 10/19/2018 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 policy of this facility to inform and provide written information to all adult residents concerning the right to...formulate an advance directive..." Based on observation, interview, and record review, the facility failed to ensure the residents were provided written information indicating their right to accept or refuse medical or surgical treatment and to formulate an advance directive (a written statement of a person's wishes regarding his/her medical and/or surgical treatment) for six of 12 sampled residents (Residents 6, 91, 93, 10, 31, and 33). This failure had the potential for Residents 6, 91, 93, 10, 31, and 33, to not make their wishes known regarding their medical and/or surgical treatment. Findings: 1. On October 15, 2018, at 12:22 p.m., Resident 6 was observed lying in bed, alert, and verbally responsive. During a concurrent interview, Resident 6 stated the facility did not provide him any written information about his right to accept or refuse medical or surgical treatment and to formulate an advance directive. On October 16, 2018, the record of Resident 6 was reviewed. Resident 6 was admitted to the facility on April 27, 2018, with diagnoses which included absence of right toes (missing right toes), stimulant abuse (drug abuse), alcohol abuse, and absence of left leg below the knee (missing left leg). On October 16, 2018, at 4:06 p.m., the Physician Orders for Life-Sustaining Treatment (POLST- contains the physician's order for resident's wishes for treatment options), dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 312H11 Facility ID: CA240000095 If continuation sheet 4 of 32 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 10/19/2018 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 April 28, 2018, was reviewed. The section of the POLST indicating whether the resident had an advanced directive was blank. There was no documented evidence the facility provided Resident 6 with written information about an advance directive. 2. On October 15, 2018, at 10:13 a.m., Resident 91 was observed lying in bed, while receiving an intravenous (IV) infusion of an antibiotic through her peripheral IV site (injection site for infusion of medications and IV fluids) in her left forearm. On October 17, 2018, the record of Resident 91 was reviewed. Resident 91 was admitted to the facility on September 29, 2018, with diagnoses which included urinary tract infection, pneumonia (lung infection), and generalized muscle weakness. On October 17, 2018, at 9:12 a.m., the POLST, dated September 29, 2018, was reviewed. The section of the POLST indicating whether the resident had an advanced directive was blank. There was no documented evidence Resident 91 was informed and provided written information about an advanced directive. 3. On October 15, 2018, at 11:57 a.m., Resident 93 was observed lying in bed, alert, and verbally responsive. On October 17, 2018, at 11:26 a.m., Resident 93 was interviewed. Resident 93 stated she did not complete an advanced directive. On October 17, 2018, the record of Resident 93 was reviewed. Resident 93 was admitted to the facility on July 2, 2018, with diagnoses which included urinary tract infection, presence FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 312H11 Facility ID: CA240000095 If continuation sheet 5 of 32 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 10/19/2018 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 of right artificial hip joint (right hip replacement), and respiratory failure (difficulty breathing). On October 17, 2018, at 11:26 a.m., the POLST, dated October 2, 2018, was reviewed. The section of the POLST indicating whether the resident had an advanced directive was blank. There was no documented evidence Resident 93 was informed and provided written information about an advanced directive. On October 16, 2018, at 4:09 p.m., the ADON was interviewed. The ADON stated the process for the residents to obtain an advanced directive was to speak with the resident during the admission process and determine if the resident had an advanced directive, then the Director of Social Services (SS) reviewed the advanced directive with the resident. The DON stated if the resident did not have an advanced directive, the SS offered the resident an advanced directive, and assisted the resident in completing the advanced directive. The ADON confirmed each facility resident should be provided written information about an advanced directive. On October 18, 2018, at 8:35 a.m., the records for Residents 6, 91, and 93, were reviewed with the SS. During a concurrent interview, the SS acknowledged written information about advance directives was not provided to Residents 6, 91, and 93. The SS stated Residents 6, 91 and 93, should have been provided with written information about an advance directive.

F623 Notice Requirements Before FORM CMS-2567(02-99) Previous Versions Obsolete

F623 Event ID: 312H11 11/09/2018 Facility ID: CA240000095 If continuation sheet 6 of 32 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 10/19/2018 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) SS=D Transfer/Discharge CFR(s): 483.15(c)(3)-(6)(8) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State LongTerm Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 312H11 Facility ID: CA240000095 If continuation sheet 7 of 32 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 10/19/2018 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 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 312H11 Facility ID: CA240000095 If continuation sheet 8 of 32 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 10/19/2018 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 §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l). This REQUIREMENT is not met as evidenced by: 2. On October 18, 2018, Resident 10's record was reviewed. The record indicated Resident 10 was originally admitted to the facility on August 20, 2018, with diagnoses including end stage renal (kidney) disease with dependence on dialysis (a medical process that substitutes for the normal function of the kidney), cancer of the kidney and colon, gastrointestinal (pertaining to the stomach and/or intestines) hemorrhage (bleeding), and gangrene (death and decomposition of body tissue). The physician's order, dated August 22, 2018, at 8:04 a.m., indicated, "SEND TO (NAME OF ACUTE HOSPITAL) ED (emergency department) FOR BLOOD TRANSFUSION..." The document titled, "Progress Notes," dated August 22, 2018, at 8:06 a.m., indicated, "...RECEIVED ORDERS TO: SEND TO (name of acute hospital) ED (emergency department) FOR BLOOD TRANSFUSION..." On October 18, 2018, at 9:30 a.m., an interview and record review were conducted with the SS. The SS confirmed Resident 10 was transferred from the facility to the acute hospital on August 22, 2018. The SS confirmed there was no FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 312H11 Facility ID: CA240000095 If continuation sheet 9 of 32 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 10/19/2018 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 documentation indicating a notice of proposed transfer was given to Resident 10 or his representative, and a copy sent to the State Long-Term Care Ombudsman. On October 18, 2018, at 5 p.m., an interview and record review were conducted with the SS. When asked if the notice of Resident 10's transfer to the acute hospital on August 22, 2018, should have been sent to the State LongTerm Care Ombudsman, the SS stated, "Yes." The facility policy and procedure titled, "Transfer and Discharge Notice," revised May 2017, indicated, "...It is the policy of this facility to provide residents with written notice of an impending transfer or discharge...Should it become necessary to transfer or discharge a resident from our facility, a representative of administration will provide the resident and family member (representative/sponsor) with a written notice of the transfer or discharge..." The facility was unable to provide a policy indicating the need to send a copy of the notice of proposed transfer or discharge to a representative of the Office of the State LongTerm Care Ombudsman. Based on interview and record review, the facility failed to ensure notification of transfer or discharge was provided to the residents or the resident representatives and to the State LongTerm Care Ombudsman for two of 12 sampled residents (Residents 5 and 10) when: 1. For Resident 5, there was no documented evidence a written proposed notice of transfer was provided to the resident and to the State Long-Term Care Ombudsman when Resident 5 was transferred to the acute hospital on June FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 312H11 Facility ID: CA240000095 If continuation sheet 10 of 32 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 10/19/2018 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 25, 2018; and 2. For Resident 10, there was no documented evidence a written proposed notice of transfer/discharge was provided to the resident/resident representative, and to the State Long-Term Care Ombudsman when Resident 10 was transferred to the acute hospital on August 22, 2018. These failures caused Residents 5 and 10 to not be aware of the circumstances related to their transfer or discharge, the information about the appeal process and their appeal rights, and the contact information of the ombudsman. These failures also increased the potential for the State Long-Term Care Ombudsman to not be aware of Residents 5 and 10's transfer or discharge to the acute hospital. Findings: 1. On October 15, 2018, at 11:22 a.m., Resident 5 was interviewed. Resident 5 stated she was hospitalized in June 2018, for "bloating in her stomach." On October 16, 2018, Resident 5's record was reviewed. Resident 5 was originally admitted to the facility on January 21, 2018, with diagnoses which included cirrhosis of liver (scarring of the liver). The document titled, "Progress Notes," indicated,"...June 25, 2018, at 5:06 p.m., PT. (patient) SEND TO (name of acute hospital) ER (emergency room) FOR EVAL (evaluation) AND TX (treatment) AS INDICATED..." The physician order, dated June 25, 2018, at 5:07 p.m., indicated, "SEND TO (name of acute FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 312H11 Facility ID: CA240000095 If continuation sheet 11 of 32 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 10/19/2018 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 hospital) ER FOR EVAL AND TX AS INDICATED one time only for ER until ..." There was no documented evidence Resident 5 received a written notice of transfer or discharge when Resident 5 was transferred to the acute hospital on June 25, 2018. There was no documented evidence a copy of the notice of transfer or discharge was sent to State Long-Term Care Ombudsman. On October 19, 2018, at 8:16 a.m., the Director of Social Services (SS) was interviewed. The SS confirmed there was no written proposed notice of transfer or discharge completed and provided to the resident and to the State LongTerm Care Ombudsman for Resident 5 when the resident was transferred to the acute hospital on June 25, 2018. The SS stated the proposed notice of transfer or discharge should have been completed and a copy should have been provided to Resident 5 and to the State Long-Term Care Ombudsman.

F655 SS=D Baseline Care Plan CFR(s): 483.21(a)(1)-(3)

F655 11/09/2018 §483.21 Comprehensive Person-Centered Care Planning §483.21(a) Baseline Care Plans §483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must(i) Be developed within 48 hours of a resident's admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited toFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 312H11 Facility ID: CA240000095 If continuation sheet 12 of 32 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 10/19/2018 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) Initial goals based on admission orders. (B) Physician orders. (C) Dietary orders. (D) Therapy services. (E) Social services. (F) PASARR recommendation, if applicable. §483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan(i) Is developed within 48 hours of the resident's admission. (ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section). §483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident's medications and dietary instructions. (iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (iv) Any updated information based on the details of the comprehensive care plan, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed ensure interventions necessary for respiratory care needs were included in the baseline care plan, for one of one resident (Resident 139). This failure increased the potential for Resident 139 to experience complications related to breathing, such as shortness of breath, infection, and respiratory failure (failure of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 312H11 Facility ID: CA240000095 If continuation sheet 13 of 32 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 10/19/2018 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 lungs to function properly). Findings: On October 15, 2018, at 3:41 p.m., Resident 139 was observed in his bed. Resident 139 was observed to have an oxygen canula (small tube to the nostrils that administers oxygen) on and his oxygen concentrator was observed to be on. Resident 139 was observed to be coughing intermittently and to have some shortness of breath. Resident 139 requested staff to position him with the head of the bed elevated with pillows behind his back to improve his breathing. On October 15, 2018, at 4:01 p.m., Licensed Vocational Nurse (LVN) 4, was observed to assess Resident 139's lung sounds. LVN 4 was observed to administer administer a breathing treatment (the administration of medication by inhalation using a device called a nebulizer) to Resident 139. On October 18, 2018, Resident 139's record was reviewed. The record indicated he was admitted to the facility on October 12, 2018, with diagnoses including malignant pleural effusion (an abnormal amount of fluid in the space between the layers of tissue that line the lungs caused by cancer) and acute respiratory failure with hypoxia (low oxygen levels). The "Initial Admission Record," dated October 12, 2018, at 7:48 p.m., indicated, "Pulmonary (lung) System...Does the Resident have a Pulmonary Diagnosis...Yes...Lungs Clear...No...Diminished...Bilateral (both) Lungs...Oxygen...Yes..." The "Progress Notes," dated October 12, 2018, at 9:28 p.m., indicated, "...Admission Note...Dx (diagnosis) of acute respiratory failure with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 312H11 Facility ID: CA240000095 If continuation sheet 14 of 32 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 10/19/2018 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 hypoxia...cancer of thyroid with mets (metastasis- spread) to lungs...pleural effusion...O2 (oxygen) at 2 LPM (liters per minute) via NC (nasal canula)...diminished lung sounds (would indicate lungs were not functioning optimally), Pleurex catheter (a tube inserted in the lungs which was used to drain fluid out) in place..." On October 18, 2018, at 11:57 a.m., an interview and review of Resident 139's record were conducted with LVN 3. LVN 3 stated Resident 139's baseline care plan did not include any interventions regarding Resident 139's respiratory care. When asked if it should have been included in the baseline care plan, LVN 3 stated, "If it's the primary diagnosis, yes." LVN 3 reviewed Resident 139's record and confirmed his primary diagnosis was malignant pleural effusion. LVN 3 confirmed the respiratory care and treatment should have been included in Resident 139's baseline care plan. The facility policy and procedure titled, "Comprehensive Person-Centered Care Planning," dated August 2017, was reviewed. The policy indicated, "...It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measureable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs...The IDT team will also develop and implement a baseline care plan for each resident...that includes minimum healthcare information necessary to properly care for each resident...Within 48 hours of the resident's admission, the facility will develop and implement a baseline care plan that includes instructions needed to provide effective and person-centered care..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 312H11 Facility ID: CA240000095 If continuation sheet 15 of 32 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 10/19/2018 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)

F656 Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) SS=D ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 11/09/2018 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 312H11 Facility ID: CA240000095 If continuation sheet 16 of 32 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 10/19/2018 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 section. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure bilateral heel protectors were included in the comprehensive care plan for one of one resident (Resident 33). This failure increased the possibility for Resident 33 to develop skin breakdown and bed sores. Findings: On October 16, 2018, at 10:09 a.m., Resident 33 was observed lying in his bed. Both of Resident 33's feet were observed to be hanging off the edge of his bed. Resident 33 was observed not have heel protectors on both of his feet. On October 17, 2018, Resident 33's record was reviewed. The record indicated Resident 33 was admitted to the facility on December 27, 2017, with diagnoses including end stage renal (kidney) disease with dependence on dialysis (a medical process that substitutes for the normal function of the kidneys), and diabetes (high blood sugar). On October 17, 2018, Resident 33's record was reviewed. The "Progress Notes," dated September 23, 2018, at 12:38 p.m., indicated, "...Patient c/o (complaining of) feeling sore to his heels, particularly the left lateral side...Patient...asked about heel protectors. Heel protectors...per (name of nurse practitioner)...to maintain skin integrity..." The document titled, "Order Summary Report," indicated, "...Bilateral (for both sides/feet) heel protectors while in bed every shift for Maintain FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 312H11 Facility ID: CA240000095 If continuation sheet 17 of 32 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 10/19/2018 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 (sic) skin integrity...," was ordered on September 23, 2018. The Minimum Data Set (MDS - an assessment tool), dated October 2, 2018, indicated Resident 33's Brief Interview for Mental Status (BIMS - assessment of cognition) was 14 (in which a score of 13-15 indicates cognitively intact). On October 17, 2018, at 3:23 p.m., an observation and concurrent interview were conducted with Resident 33. Resident 33 was in bed, awake and alert. Resident 33 was observed not to have bilateral heel protectors on his feet. Resident 33 was asked if he had cushioned booties to wear on his feet. Resident 33 stated, "Yes, but I don't know where they are." Resident 33 stated he did not remember the last time he had them on and it had been "awhile." When asked if he would wear them if he had them, he stated, "Yes, I would." On October 17, 2018, at 4:16 p.m., an interview was conducted with Licensed Vocational Nurse (LVN) 5. LVN 5 stated she received the order for the bilateral heel protectors for Resident 33 because Resident 33 was complaining of heel pain. On October 17, 2018, at 4:17 p.m., an observation of Resident 33 was conducted with LVN 5. LVN 5 confirmed Resident 33 did not have heel protectors on his feet. On October 17, 2018, at 4:18 p.m., Resident 33's record was reviewed with LVN 5. The section of the electronic documentation titled, "Task: Pressure Reducing Devices," was reviewed. LVN 5 stated the column titled, "Other device on feet," is where the certified nurses aides documented if Resident 33 had FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 312H11 Facility ID: CA240000095 If continuation sheet 18 of 32 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 10/19/2018 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 heel protectors on his feet. LVN 5 stated there was no documentation indicating Resident 33 had bilateral heel protectors on his feet on October 4, 2018, and from October 6, 2018, to October 17, 2018 (total of 12 days). On October 17, 2018, at 4:29 p.m., an interview and concurrent review of Resident 33's record were conducted with LVN 5. LVN 5 stated the bilateral heel protectors were not included in Resident 33's comprehensive care plan. When asked if the heel protectors should be included in Resident 33's comprehensive care plan, LVN 5 stated, "Yes." The facility policy titled, "...Comprehensive Person-Centered Care Planning," dated August 2017, indicated, "...It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident...The comprehensive care plan...will include resident's needs..."

F684 SS=D Quality of Care CFR(s): 483.25

F684 11/09/2018 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the weight of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 312H11 Facility ID: CA240000095 If continuation sheet 19 of 32 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 10/19/2018 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 one of two residents (Resident 136) was accurately assessed for maintenance, when Resident 126 was not weighed within 48 hours of readmission. This failure had the potential for the facility to not detect further weight loss and could cause a delay in weight loss treatment for Resident 136. Findings: On October 15, 2018, at 11:05 a.m., Resident 136 was observed in his bed, awake, and alert. Resident 136's family member (FM) was at the bedside and stated Resident 136 had been back to the hospital a couple of times since he was first admitted to the facility and had "lost weight." The FM stated he also had lymphoma (a type of blood cancer) and prostate cancer. On October 17, 2018, Resident 136's record was reviewed. The record indicated Resident 136 was admitted to the facility on September 18, 2018, and was readmitted on October 12, 2018, with diagnoses including kidney failure and non-Hodgkin lymphoma. Resident 136's care plan, with a start date of September 19, 2018, indicated, "...Will maintain adequate nutritional status as evidenced by maintaining weight..." Resident 136's care plan, for the admission date of October 12, 2018, indicated, "...Will maintain adequate nutritional status as evidenced by maintaining weight..." The "RD (registered Dietitian)- Nutrition Risk Review," dated September 21, 2-18, indicated, "...GOALS 1. Stable wt (weight) (fluc [fluctuation] < 5 %/ mo [less than five percent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 312H11 Facility ID: CA240000095 If continuation sheet 20 of 32 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 10/19/2018 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 month])..." Resident 136's Minimum Data Set (MDS - an assessment tool), dated October 1, 2018, indicated Resident 136 weight was 150 pounds (lbs). The document indicated Resident 136's nutritional status was addressed in the care plan. The document titled, "LN (Licensed Nurse)Nutrition Interdisciplinary Team (IDT) UPDATE," dated October 3, 2018, was reviewed. The document indicated, "...Resident is noted with a 6% (percent) weight loss (10 lbs) since 1st (first) admission on 09/18/2018..." The document titled, "Weights and Vitals Summary," indicated Resident 136 weighed 152 lbs on September 19, 2018, and 142 lbs on October 3, 2018 (a 6.58% weight loss in two weeks). There was no weight recorded after October 3, 2018. Resident 136 was readmitted to the facility on October 12, 2018. There was no weight recorded since Resident 136 was readmitted. On October 17, 2018, at 1:53 p.m., an interview and record review were conducted with Licensed Vocational Nurse (LVN) 2. LVN 2 stated Resident 136 had lost six percent of his weight. LVN 2 stated there was no documentation indicating Resident 136 was weighed since admission on October 12, 2018. LVN 2 stated residents should be weighed the day after admission. LVN 2 stated Resident 136 should have been weighed the day after admission on October 12, 2018. The facility policy and procedure titled, "...Nursing Administration," revised June, 2018, was reviewed. The policy indicated, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 312H11 Facility ID: CA240000095 If continuation sheet 21 of 32 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 10/19/2018 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 "Assessment...Each resident is to be weighed within forty-eight (48) hours of re/admission..."

F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer F686 11/09/2018 SS=D CFR(s): 483.25(b)(1)(i)(ii) §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure bilateral (for both feet/sides) heel protectors were in place, as ordered by the physician, for one of one resident (Resident 33). This failure increased the possibility for Resident 33 to develop skin breakdown and bed sores. Findings: On October 16, 2018, at 10:09 a.m., Resident 33 was observed lying in his bed. Resident 33 was observed to have both of his feet hanging by the edge of his bed. Resident 33 was not observed to have bilateral heel protectors on his feet. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 312H11 Facility ID: CA240000095 If continuation sheet 22 of 32 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 10/19/2018 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 October 17, 2018, Resident 33's record was reviewed. The record indicated Resident 33 was admitted to the facility on December 27, 2017, with diagnoses including end stage renal (kidney) disease with dependence on dialysis (a process that substitutes for the normal function of the kidneys) and diabetes (high blood sugar). The "Progress Notes," dated September 23, 2018, at 12:38 p.m., indicated, "...Patient c/o (complaining of) feeling sore to his heels, particularly the left lateral side...Patient...asked about heel protectors. Heel protectors...per (name of nurse practitioner)...to maintain skin integrity..." The Minimum Data Set (MDS - an assessment tool), dated October 2, 2018, indicated Resident 33's Brief Interview for Mental Status (BIMS - assessment of cognition) was 14 (in which a score of 13-15 indicates cognitively intact). The document titled, "Order Summary Report," dated October 17, 2018, indicated, "...Bilateral heel protectors while in bed every shift for Maintain (sic) skin integrity..." On October 17, 2018, at 3:23 p.m., an observation and concurrent interview was conducted with Resident 33. He was in bed, awake, and alert. Resident 33 did not have bilateral heel protectors on his feet. Resident 33 was asked if he had cushioned booties to wear on his feet. Resident 33 stated, "Yes, but I don't know where they are." Resident 33 stated he did not remember the last time he had them on and it had been "awhile." When asked if he would wear them if he had them, he stated, "Yes, I would." On October 17, 2018, at 4:16 p.m., an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 312H11 Facility ID: CA240000095 If continuation sheet 23 of 32 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 10/19/2018 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 interview was conducted with Licensed Vocational Nurse (LVN) 5. LVN 5 stated she received the order for the bilateral heel protectors for Resident 33 because he was complaining of heel pain. On October 17, 2018, at 4:17 p.m., an observation of Resident 33 was conducted with LVN 5. LVN 5 confirmed Resident 33 did not have heel protectors on his feet. LVN 5 confirmed Resident 33 should have bilateral heel protectors on, as ordered by the physician. On October 17, 2018, at 4:18 p.m., Resident 33's record was reviewed with LVN 5. The section of the electronic documentation titled, "Task: Pressure Reducing Devices," was reviewed. LVN 5 stated the column titled, "Other device on feet," is where the certified nurses aides document if Resident 33 had on the heel protectors. LVN 5 confirmed there was no documentation indicating Resident 33 had bilateral heel protectors on his feet on October 4, 2018, and from October 6, 2018, to October 17, 2018 (total of 12 days).

F695 SS=D Respiratory/Tracheostomy Care and Suctioning F695 CFR(s): 483.25(i) 11/09/2018 § 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 312H11 Facility ID: CA240000095 If continuation sheet 24 of 32 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 10/19/2018 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 review, the facility failed to ensure the oxygen concentrator filter was free of an accumulation of grayish substance, for one of one resident (Resident 139). This failure increased the potential for Resident 139 to experience complications, such as infection, related to his respiratory status. Findings: On October 15, 2018, at 11:01 a.m., Resident 139 was observed in his bed. Resident 139 was observed to have an oxygen canula (small tube to the nostrils that administers oxygen) on, and his oxygen concentrator was on at 2 liters (L). The filter of Resident 139's oxygen concentrator was observed to have an accumulation of grayish substance. On October 15, 2018, at 3:41 p.m., Resident 139 was observed in his bed. Resident 139 was observed to be coughing intermittently and had some shortness of breath. Resident 139 was observed to request staff to position him with the head of the bed elevated with pillows behind his back to improve his breathing. On October 15, 2018, at 4:01 p.m., Licensed Vocational Nurse (LVN) 4, was observed to assess Resident 139's lung sounds. LVN 4 was then observed to administer inhaled medication to Resident 139. On October 15, 2018, at 4:17 p.m., Resident 139's oxygen concentrator filter was observed with LVN 4. When asked what was on the oxygen concentrator filter, LVN 4 stated, "It's dirty." When asked if the filter should be like that, LVN 4 stated, "No." On October 18, 2018, Resident 139's record was reviewed. The record indicated he was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 312H11 Facility ID: CA240000095 If continuation sheet 25 of 32 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 10/19/2018 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 admitted to the facility on October 12, 2018, with diagnoses including malignant pleural effusion (an abnormal amount of fluid in the space between the layers of tissue that line the lungs) and acute respiratory failure (failure of the lungs to function properly) with hypoxia (low oxygen levels). The "Progress Notes," dated October 12, 2018, at 9:28 p.m., indicated, "...Admission Note...Dx (diagnosis) of acute respiratory failure with hypoxia...cancer of thyroid with mets (metastasis - spread) to lungs...pleural effusion...O2 (oxygen) at 2 LPM (liters per minute) via NC (nasal canula)...diminished lung sounds (indicates lungs are not functioning optimally), Pleurex catheter (a tube inserted in the lungs which is used to drain fluid out) in place..." The "Initial Admission Record," dated October 12, 2018, at 7:48 p.m., indicated, "Pulmonary (lung) System...Does the Resident have a Pulmonary Diagnosis...Yes...Breath Sounds...Lungs Clear...No...Diminished...Bilateral (both) lungs...Oxygen...Yes..." According to the web article titled, "How to Keep Your Oxygen Equipment Clean," published by the Lung Institute on June 8, 2018, "...If you use oxygen therapy, it's important to keep your oxygen equipment clean...to ensure you receive uninterrupted, clean oxygen therapy...you have to keep the filter clean...The filter cleans the air that is coming into the machine. The filter helps catch dust, pollen, allergens, mold, dirt...The general guidelines suggest cleaning the filter at least once a month. However, sometimes additional cleaning may be required..."

F727 RN 8 Hrs/7 days/Wk, Full Time DON FORM CMS-2567(02-99) Previous Versions Obsolete

F727 Event ID: 312H11 11/09/2018 Facility ID: CA240000095 If continuation sheet 26 of 32 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 10/19/2018 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) SS=F CFR(s): 483.35(b)(1)-(3) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.35(b) Registered nurse §483.35(b)(1) Except when waived under paragraph (e) or (f) of this section, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. §483.35(b)(2) Except when waived under paragraph (e) or (f) of this section, the facility must designate a registered nurse to serve as the director of nursing on a full time basis. §483.35(b)(3) The director of nursing may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the facility had a Director of Nursing (DON) to provide oversight and guidance on the provision of care provided by nursing staff. This failure had the potential to result in the needs of the residents not being adequately assessed and met in a timely manner, and could potentially impact the quality of care delivered by licensed and non-licensed nursing staff to the residents. Findings: On October 18, 2018, at 2:20 p.m., an interview was conducted with Licensed Vocational Nurse (LVN) 3. LVN 3 stated she started as the Assistant Director of Nursing (ADON) for the facility in January 2018. LVN 3 stated the previous DON was at the facility beginning in May 2018 and left the facility in August 2018. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 312H11 Facility ID: CA240000095 If continuation sheet 27 of 32 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 10/19/2018 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 LVN 3 stated she was an LVN, not a Registered Nurse (RN). On October 18, 2018, at 2:59 p.m., an interview was conducted with the Administrator (ADM). The ADM stated there were candidates for the DON position which she intended to interview beginning the week of October 22, 2018. The ADM stated RN 1 had not been designated as the DON. The ADM also stated the facility's nurse consultant (RN 2) from corporate had been a clinical resource, but had not been designated as the DON. As of the survey exit date on October 19, 2018, two months since August 2018, the facility had not designated a DON to provide oversight, guidance, direction, and/or coordination on the provision of care by licensed and ancillary nursing staff.

F755 SS=D Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 11/09/2018 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist whoFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 312H11 Facility ID: CA240000095 If continuation sheet 28 of 32 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 10/19/2018 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 §483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure one tablet of Nitrostat (nitroglycerin - medication for chest pain) was accounted for, for one of one resident (Resident 92). These findings had the potential for Resident 92 to receive doses of medication incorrectly. Findings: On October 17, 2018, at 11:15 a.m., an inspection of the medication cart was conducted with Licensed Vocational Nurse (LVN) 1. One bottle of Nitrostat tablets 0.4 mg (milligrams), labeled with the name of Resident 92, was observed in the medication cart. LVN 1 was observed to count the tablets in the bottle. In a concurrent interview, LVN 1 stated there were 24 tablets remaining in the bottle of Nitrostat. LVN 1 confirmed the label on the bottle of Nitrostat indicated the pharmacy sent the Nitrostat to the facility on September 28, 2018. LVN 1 confirmed the label indicated the bottle contained 25 tablets. A review of Resident 92's "Medication FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 312H11 Facility ID: CA240000095 If continuation sheet 29 of 32 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 10/19/2018 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 Administration Record (MAR)" was also concurrently conducted with LVN 1. LVN 1 stated there was no documentation indicating a tablet of Nitrostat was administered to Resident 92 since the bottle was received from the pharmacy on September 28, 2018. LVN 1 stated she did not know why there was a tablet of Nitrostat unaccounted for. On October 19, 2018, Resident 92's record was reviewed. The record indicated Resident 92 was admitted to the facility on September 28, 2018, with diagnoses including hypertension (high blood pressure), hyperlipidemia (a high level of fat in the blood), atherosclerotic heart disease (a build up of fat and other substances in the blood vessels), occlusion and stenosis of the carotid artery (a narrowing and blockage of the carotid blood vessels), and aortocoronary bypass graft (heart surgery that can create new routes of blood around narrowed and blocked blood vessels). The document titled, "Order Summary Report," dated October 19, 2018, indicated, "...Nitrostat Tablet Sublingual (under the tongue) 0.4 MG (Nitroglycerin)...Give 1 tablet sublingually every 5 (five) minutes as needed...for ANGINA (chest pain) ONE TABLET Q(every)5MINUTES (sic) FOR CHEST PAIN, NTE (not to exceed) 3 (three) doses, CALL 911 IF CHEST PAIN PERSISTS AFTER 3 DOSES... ...Order Date...September 28, 2018...Start Date...September 28, 2018..." Resident 92's MARs dated September 2018 and October 2018 were reviewed. There was no documentation indicating any doses of Nitrostat were administered to Resident 92 in September and October, 2018. The facility's undated policy and procedure titled, "MEDICATION STORAGE IN THE FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 312H11 Facility ID: CA240000095 If continuation sheet 30 of 32 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 10/19/2018 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 FACILITY," indicated, "...Medications...are stored safely, securely, and properly..."

F836 SS=D License/Comply w/ Fed/State/Locl Law/Prof Std CFR(s): 483.70(a)-(c)

F836 11/09/2018 §483.70(a) Licensure. A facility must be licensed under applicable State and local law. §483.70(b) Compliance with Federal, State, and Local Laws and Professional Standards. The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. §483.70(c) Relationship to Other HHS Regulations. In addition to compliance with the regulations set forth in this subpart, facilities are obliged to meet the applicable provisions of other HHS regulations, including but not limited to those pertaining to nondiscrimination on the basis of race, color, or national origin (45 CFR part 80); nondiscrimination on the basis of disability (45 CFR part 84); nondiscrimination on the basis of age (45 CFR part 91); nondiscrimination on the basis of race, color, national origin, sex, age, or disability (45 CFR part 92); protection of human subjects of research (45 CFR part 46); and fraud and abuse (42 CFR part 455) and protection of individually identifiable health information (45 CFR parts 160 and 164). Violations of such other provisions may result in a finding of non-compliance with this paragraph. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 312H11 Facility ID: CA240000095 If continuation sheet 31 of 32 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 10/19/2018 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 observation, interview, and record review, the facility failed to ensure internal medications and external medications were not stored together in the same compartment of the medication cart drawer. This failure had the potential for residents to receive medications through the wrong route. Findings: On October 17, 2018, at 11:15 a.m., an inspection of the medication cart was conducted with Licensed Vocational Nurse (LVN) 1. One compartment in the medication cart drawer was observed to contain one box of Dulcolax (medication used for constipation) 10 mg (milligrams) suppositories together with one box of Cepacol (medication for sore throat) lozenges. In a concurrent interview, LVN 1 confirmed the suppositories and the lozenges were not supposed to be stored together in the same compartment. The undated facility policy and procedure titled, "MEDICATION STORAGE IN THE FACILITY," was reviewed. The policy indicated, "...Orally administered medications are kept separate from externally used medications, such as suppositories..." According to Title 22, Division 5, Chapter 3, 72357 (e), "External use drugs in liquid, tablet, capsule or powder form shall be stored separately from drugs for internal use." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 312H11 Facility ID: CA240000095 If continuation sheet 32 of 32