Health inspection·October 26, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to evaluate the status and to document weekly assessments for one of three sampled residents' (Resident 1) right big toe discoloration, in accordance with the facility's policy and procedures. Residents Affected - Few This failure led to facility staff being unaware of the changes in the condition of Resident 1's right big toe, which could delay the provision of the appropriate treatment resulting in worsening of the resident's wound. Findings: On September 21, 2023, 10:42 a.m., an unannounced visit was made to the facility to investigate a quality care issue. A review of Resident 1's medical records was conducted, and indicated the resident was admitted to the facility on [DATE], with diagnoses which included type 2 diabetes mellitus (disease which causes elevated blood sugar levels, which can result in circulatory problems). A review of Resident 1's admission Skin Assessment, by the admission Nurse dated December 31, 2022, indicated, R (Right) Greater Toe Discoloration. A review of admission Skin Assessment, dated January 2, 2023, by the Treatment (Tx) Nurse, indicated (Right) Great Toe Discoloration. A review of Resident 1's weekly skin evaluation indicated no weekly skin assessments of Resident 1's right big toe discoloration was documented between his admission date of December 31, 2022, and discharge date of January 26, 2023. A review of Resident 1's physician order dated January 2, 2023, indicated, . (Right) GREAT TOE DISCOLORATION: MONITOR FOR SKIN INTEGRITY FOR ANY BREAKDOWN REPORT TO MD (Medical Doctor) every day shift for 21 days . A review of Resident 1's Treatment Administration Record (TAR), for the month of January 2023, indicated, Resident 1's right great toe was being monitored for discoloration daily between the dates of January 3, 2023, to January 23, 2023. The TAR indicated initials were entered by the Tx nurse. A review of the Interdisciplinary Team's (IDT) Meeting notes dated January 5, 2023, at 2:08 p.m., was conducted, and indicated, . 7c. Special Treatments, Procedures and Devices . MONITOR FOR SKIN (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 555613 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555613 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Care and Wellness 3401 Lemon Street Riverside, CA 92501 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)