Health inspection·December 6, 2023

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated line on the side of the bottle and shake well. Half of the prep is to be taken at 6pm on the night prior to the procedure drink 8 ounces every 10 minutes until the container is half empty, and the other half is to be taken 6 to 8 hours prior to the scheduled time of the procedure drink 8 ounces every 10 minutes until the container is empty .Order Date 11/12/2023 . - Administer milk of magnesia (a laxative) on November 9, 10 and 11, 2023 to .start in the morning and finish by the evening: Take one bottle of 8-ounce milk of magnesia over the counter mint or original flavor (No cherry flavor) . The Medication Administration Record (MAR) for November 2023 was reviewed. The document indicated the following: - .Laxative Prep #2: November 12, 2023 Sun morning fill the container with water to the indicated line on the side of the bottle and shake well. Half of the prep is to be taken at 6pm on the night prior to the procedure drink 8 ounces every 10 minutes until the container is half empty, and the other half is to be taken 6 to 8 hours prior to the scheduled time of the procedure drink 8 ounces every 10 minutes until the container is empty . There was one licensed nurse (LN) initial each on November 12, 2023 PM (afternoon) and NOC (night) shifts, and one LN initial on November 13, 2023 AM (morning) shift, signifying the laxative preparation solution was administered during these shifts. - .GOLYTELY (brand name for a type of laxative preparation) ORAL SOLUTION RECONSTITUED 227.1 GM (gram- unit of measurement) USE AS DIRECTED ON THE DAY BEFORE COLONOSCOPY ON 11/11/23,11/12/23 every shift for 1 Day -Order Date- 11/12/2023 . There was no documented evidence the Golytely solution was administered to Resident 5 on November 11, 2023. There was no documented evidence the milk of magnesia was administered to Resident 5 on November 9, 10, and 11, 2023, according to the physician's orders. Resident 5's Progress Notes, dated November 13, 2023, at 6:45 a.m., indicated, .Patient continued to have dark watery stools noted when patient's daughter [NAME] came in the morning at 6am (6 a.m.) prior to her appointment. Patient had taken most of the [NAME] (sic) medication but refused after a certain point in the night to take more. Per the daughter there was no point in going to the appointment due to the dark stools as the (sic) should be clear according to (name of doctor). Patient's daughter called to cancel the colonoscopy appointment . On November 6, 2023, at 4:59 p.m., a concurrent interview and review of Resident 5's record was conducted with the Director Nursing (DON). The DON stated there was no documented evidence the milk of magnesia was administered to Resident 5 on November 9, 10 and 11, 2023, nor was there documented evidence the Golytely solution was administered to Resident 5 on November 11, 2023. The DON stated the bowel preparation medications should have been administered to Resident 5 as ordered by the physician, and should have been documented as given to the resident. The facility policy and procedure titled, Administration of Drugs/Treatment, revised May 2007, was reviewed. The policy indicated, .It is the policy of the facility that medications .shall be administered as prescribed by the attending physician .Procedures: .Medications .must be administered in accordance with the written orders of the attending physician .The nurse administering the medications must initial the resident's eMAR (electronic MAR) .on the appropriate line and date for that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555613 If continuation sheet Page 2 of 17 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 12/06/2023 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)

F 0684 specific day . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555613 If continuation sheet Page 3 of 17 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 12/06/2023 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)

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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 ensure a resident who was receiving dialysis (the process of removing waste products and excess fluid from /the body when the kidneys are not able to adequately filter the blood) received more than the prescribed fluid per day, for one of two sampled residents reviewed for dialysis (Resident 285) (Cross Reference F656). Residents Affected - Few This failure placed Resident 285's care needs to go unmet and had the potential to result in fluid overload. Findings: On December 3, 2023, at 12:15 p.m., a concurrent lunch meal observation, interview, and record review was conducted with Resident 285 at the bedside. Resident 285's meal tray ticket was reviewed and indicated .Renal diet .4 ounces (oz - a unit of measurement) (120 ml [milliliter - unit of measurement]) cranberry juice, 4 oz (120 ml) milk Resident 285's meal ticket did not indicate if the resident required fluid restriction. Resident 285 was observed being served 120 ml cranberry juice and 120 ml milk with her lunch tray. In a concurrent interview, Resident 285 stated she had poor appetite. On December 3, 2023, at 12:32 p.m., Resident 285 was observed to have eaten only 75% of the dessert and did not touch the beverages served on her lunch meal tray. On December 3, 2023, Resident 285's record was reviewed. Resident 285's admission Record, indicated Resident 285 was admitted to the facility on [DATE], with diagnoses which included end stage renal disease (ESRD - a disease with kidney failure) and dependence on renal dialysis. Resident 285's Order Summary Report, included a physician's order, dated November 23, 2023, which indicated, .1500 ml fluid restriction breakdown as follows .AM/Dietary: 240 ml .Lunch meal dietary 120 ml .Dinner 240 ml . On December 4, 2023, at 12:35 p.m., Resident 285 was observed to have 4 oz (120 ml) of cranberry juice and 4 oz milk. The meal ticket indicated Resident 285 was to receive 4 oz of cranberry juice and 4 oz milk during lunch. On December 4, 2023, at 12:53 p.m., Registered Dietitian (RD) 1 was interviewed. RD 1 verified Resident 285 was served 4 oz milk and 4 oz cranberry juice. On December 5, 2023, at 9:40 a.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN) 1. She stated Resident 285 has a physician order for 1500 ml fluid restriction with specific fluid breakdown with each meal and ordered to the kitchen. She stated the physician order indicated Resident 285 was to receive 120 ml fluid during lunch meal. Resident 285's meal ticket was concurrently reviewed with LVN 1, she stated Resident 285 received 120 ml of cranberry juice and 120 ml of milk during lunch. She stated Resident 285 received extra 120 ml of fluid during lunch. LVN 1 stated the physician order for fluid restriction breakdown was not transferred into Resident 285's meal tray ticket. LVN 1 stated there was a potential risk for Resident 285 to receive extra fluid than the physician ordered and could lead to fluid overload. On December 5, 2023, at 10:47 a.m., a concurrent interview and record review was conducted with the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555613 If continuation sheet Page 4 of 17 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 12/06/2023 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)

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Director of Nursing (DON). She stated Resident 285 had a physician order for 1500 ml fluid restriction with specific breakdown per meal the kitchen should give and how much nursing staff could give per shift. The DON stated the Certified Dietary Manager (CDM) was supposed to receive the dietary communication slip regarding Resident 285's physician ordered for fluid restriction and each meal fluid breakdown on November 23, 2023. She stated after comparing Resident 285's meal ticket and physician order, the DON acknowledged Resident 285 received extra 120 ml with breakfast and 120 ml for lunch and totally extra 240 ml fluid per day. The DON stated there could be potential risk for Resident 285 to get extra fluid and could worsen the kidney functions and fluid overload. The DON expectation was for the nursing staff to check the physician fluid restriction ordered and the dietary staff should serve the amount of fluid as prescribed by the physician on each meal tray. On December 5, 2023, at 12:02 p.m., a concurrent interview and record review was conducted with the CDM. The CDM admitted she was unable to locate the dietary communication slip regarding physician ordered for fluid restriction and each meal fluid breakdown for Resident 285 on November 23, 2023. The CDM stated Resident 285's meal tray ticket did not indicate the breakdown for the ordered fluid restriction. The CDM stated, Maybe I misplaced the order. On December 5, 2023, at 3:36 p.m., Registered Dietitian (RD) 1 was interviewed. RD 1 stated she was in charge to breakdown Resident 285's fluid restriction and nursing was in charge to call the doctor to get approval for the RD recommendation. She stated a dietary communication slip was to be given to the kitchen indicating the fluid restriction breakdown ordered for each meal. RD 1 stated the CDM was in charge to put the fluid restriction breakdown with each meal into the tray card system (computer program). She stated the tray card system would generate the amount of fluids as per physician order in the meal tray tickets. She stated the dietary staff then would serve the amount of fluid as indicated in the meal tray tickets to the residents. RD 1 stated there could be potential risk for fluid overload, affect the dialysis treatment, hydration status, and kidney function, when prescribed fluids were not followed. RD 1 stated her expectation was the dietary staff should have followed the fluid restriction ordered by the physician. A review of the facility's policy and procedure titled Physician Orders, revised May 2015, indicated, .It is the policy of this facility that all physician orders must be followed by the facility licensed nurses or authorized personnel . A review of the facility's undated policy and procedure titled Fluid Restrictions, indicated, .The Physician will order the fluid restriction in total cc's (ml's) per 24 hours .Nursing will provide a diet order communication form for all fluid restriction orders . A review of the facility's undated policy and procedure titled Tray Card System, indicated, .Each meal tray at breakfast, lunch and dinner will have a tray card (meal tray ticket) which designates the resident's name, diet .The Food and Nutrition Director (CDM) is responsible for the tray card system . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555613 If continuation sheet Page 5 of 17 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 12/06/2023 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure there were no expired intravenous (IVwithin a vein) supplies in the IV cart. This failure had the potential to expose residents to bloodborne pathogens (infectious germs in the blood) and diseases. Findings: On [DATE] at 3:17 p.m., an IV cart observation was conducted with the Registered Nurse (RN). The following expired IV supplies were observed inside the IV cart: - One 20 Gauge IV catheter needle (a tube that allows medication or fluids to be directly administered through the veins), with an expiration date of [DATE]; and - One Medtronic quick-set tubing (brand name of IV tubing), with an expiration date of [DATE]. In a concurrent interview with the RN, she stated the IV catheter needle and the Medtronic quick-set tubing were both expired and should have been removed from the IV cart. On [DATE], at 3:25 p.m., an interview was conducted with the Director of Nursing (DON). The DON saw the IV catheter and the Medtronic quick-set tubing and stated both the tubing and the IV catheter were expired and should have been removed from the IV cart. The facility's policy and procedure titled Equipment and Supplies, dated [DATE], was reviewed. The policy indicated, .Intravenous therapy and supplies if facility provides such services .If .supplies are expired must be discarded . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555613 If continuation sheet Page 6 of 17 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 12/06/2023 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)

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure dietary staff were able to carry out the functions of food and nutrition services safely and effectively when: 1. Dietary Aide (DA) 1 did not follow manufacturer's guideline time length for testing the red bucket Quaternary (Quat) sanitizer (sanitizing solution used for sanitizing food contact surfaces). 2. Certified Dietary Manager (CDM) was unable to accurately verbalized how long the [NAME] test strip need to dip into the red bucket Quat sanitizer for testing the concentration of Quat sanitizer. 3. DA 3 did not follow manufacturer's guideline time length for placing kitchen wares into sanitizing solution in sanitizer sink. 4. DA 3 was unable to accurately test the sanitizing solution in sanitizer sink. 5. Registered Dietitian (RD) and CDM were unable to accurately verbalized how long kitchen wares need to place into the sanitizing solution in sanitizer sink. 6. Dietary staff did not use proper method to defrost meat. (Cross Referred F812) These failures had the potential to cause foodborne illness for 35 out of 35 sampled residents who received foods from the kitchen. 1. On December 3, 2023, at 9:56 a.m., a concurrent observation and interview was conducted with DA 1. DA 1 was observed to test the red bucket Quat sanitizer with the Quat sanitizer test strip. DA 1 was observed to only dipped the Quat test strip in the Quat sanitizer for 5 (five) seconds. In a concurrent interview, DA 1 stated she needed to dip the Quat sanitizer test strip in the Quat sanitizer solution for 16 seconds for testing the concentration. On December 4, 2023, at 3:01 p.m., RD 1 was interviewed. RD 1 stated the Quat sanitizer test strip needed to dip in Quat sanitizer solution for 10 seconds for testing the concentration. RD 1 stated a false reading of the concentration of Quat sanitizer could happen if the manufacturer's guideline time length for testing concentration of Quat sanitizer was not followed properly. RD 1 further explained food contact surfaces could not be properly sanitize if the Quat sanitizer is not in the right concentration and could lead to food born illness and cross contamination. RD 1 stated her expectation was for the dietary staff to follow the manufacturer instructions for testing the Quat sanitizer solution. A review of the undated facility's Quat sanitizer test strip container's instructions, indicated, .Dip paper in quat solution .for 10 (ten) seconds . A review of the facility's policy and procedure titled, Quaternary Ammonium Log Policy, indicated, .The concentration of the ammonium in the Quaternary sanitizer will be tested to ensure the effectiveness of the solution .Read instructions on Quaternary container and test strips for .length of time the strip needs to be in contact with the solution .Follow container and test strip instructions . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555613 If continuation sheet Page 7 of 17 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 12/06/2023 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)

F 0802 Level of Harm - Minimal harm or potential for actual harm A review of the facility's document titled, Job Description Dietary Aide, dated December 27, 2021, indicated, . Position Summary: To provide assistance in all dietary functions in accordance with current applicable federal, state, and local standards, guidelines and regulations .The assurance that quality nutritional service are provided on a daily basis and that the dietary department is maintained in a clean, safe and sanitary manner . Residents Affected - Some 2. On December 3, 2023, at 10:08 a.m., a concurrent interview and record review with the CDM was conducted. The CDM stated she agreed with DA 1 statement regarding the Quat test strip needed to be dipped for 16 seconds to test the Quat sanitizer concentration in the red bucket. Reviewed the Quat sanitizer test strip container's instructions with the CDM. The CDM read the instructions and stated, Dip paper in quat solution .for 10 seconds . On December 4, 2023, at 3:01 p.m., an interview with RD 1 was conducted. RD 1 stated the Quat sanitizer test strip needed to be dipped in the Quat sanitizer for 10 seconds for testing the concentration. RD 1 stated a false reading of the concentration of Quat sanitizer could happen if the manufacturer's guideline time length for testing concentration of Quat sanitizer was not followed properly. RD 1 further explained food contact surfaces could not be properly sanitize if the Quat sanitizer is not in the right concentration and could lead to food born illness and cross contamination. RD 1 stated her expectation was for the dietary staff to follow the manufacturer instructions for testing the Quat sanitizer solution. A review of the facility's policy and procedure titled, Quaternary Ammonium Log Policy, indicated, .The concentration of the ammonium in the Quaternary sanitizer will be tested to ensure the effectiveness of the solution .Read instructions on Quaternary container and test strips for .length of time the strip needs to be in contact with the solution .Follow container and test strip instructions . A review of the facility's document titled, Job Description Dietary Supervisor, dated December 27, 2021, indicated, . Position Summary: To provide assistance in all dietary functions in accordance with current applicable federal, state, and local standards, guidelines and regulations .The assurance that quality nutritional service are provided on a daily basis and that the dietary department is maintained in a clean, safe and sanitary manner . 3. On December 3, 2023, at 11:31 a.m., a concurrent observation of the 3-compartment sinks (three sinks used for cleaning kitchen wares, one for washing, one for rinsing and one for sanitizing) was conducted with DA 3. DA 3 was observed to use the 3-compartment sinks to clean the kitchen wares. DA 3 was observed to dip the kitchen wares into the sanitizing solutions in the sanitizer sink for 1 (one) second. In a concurrent interview, DA 3 stated she needed to place the kitchen wares into the sanitizing solutions in sanitizer sink for 1 (one) minute and she admitted she did not place the kitchen wares into sanitizing solutions for 1 minute. On December 4, 2023, at 3:01 p.m., an interview was conducted with RD 1, RD 2, and the CDM. RD 2 stated the dietary staff needed to place the kitchen wares into the sanitizing solution in the sanitizer sink for 1 (one) minute. RD 1 explained placing kitchen wares less than manufacturer's instructions time length could cause for the kitchen wares to be not properly sanitized. RD 1 expectation was for the dietary staff to follow the manufacturer guidelines time length to place the kitchen wares into the sanitizing solution. According to the USDA Food Code 2022, Section 4-501.114 Manual and Mechanical Ware washing Equipment, Chemical Sanitization -Temperature, pH, Concentration, and Hardness, (C) A quaternary ammonium (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555613 If continuation sheet Page 8 of 17 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 12/06/2023 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)

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some compound solution shall (2) Have a concentration as specified under § 7-204.11 and as indicated by the manufacturer's use directions included in the labeling. A review of the undated sanitizer manufacturer's use directions for 3-compartment sink cleaning procedures posted above the 3-compartment sinks, indicated, .Sanitize .Place items in sanitizing solutions for 1 minute . A review of the undated facility's policy and procedure titled, 3-Compartment procedure for manual dishwashing, indicated, .The third compartment is for sanitizing .Immerse all washed items for 1 minute . A review of the facility's document titled, Job Description Dietary Aide, dated December 27, 2021, indicated, .Position Summary: To provide assistance in all dietary functions in accordance with current applicable federal, state, and local standards, guidelines and regulations .The assurance that quality nutritional service are provided on a daily basis and that the dietary department is maintained in a clean, safe and sanitary manner . 4. On December 3, 2023, at 11:35 a.m., a concurrent observation of the 3 compartment sinks and interview with DA 3 was conducted. DA 3 was observed to check the sanitizing solution in the sanitizer sink. DA 3 was observed to dip the test strip into the sanitizing solution and compared the test strip with the ppm (parts per million -a unit of measurement) reference colors on the test strip container. In a concurrent interview, DA 3 stated the ppm should be between 0 -100 ppm. On December 3, 2023, at 12:04 p.m., the CDM was interviewed. She stated the ppm range should read between 200 -400 ppm when the sanitizing solution at the sanitizer sink was to be tested. According to the USDA Food Code 2022, Section 4-501.114 Manual and Mechanical Ware washing Equipment, Chemical Sanitization -Temperature, pH, Concentration, and Hardness, (C) A quaternary ammonium compound solution shall (2) Have a concentration as specified under § 7-204.11 and as indicated by the manufacturer's use directions included in the labeling. A review of the undated sanitizer manufacturer's use directions for 3 compartment sink cleaning procedures posted above the 3-compartment sinks, indicated, .Sanitize .Test to assurance proper solution strength 200 ppm - 400 ppm . A review of the undated facility's policy and procedure titled, 3-Compartment procedure for manual dishwashing, indicated, .The third compartment is for sanitizing .Must read 200 ppm . A review of the facility's document titled, Dietary Department Inservice/Education, dated August 11, 2023, indicated, .Manual ware washing and proper drying procedures. The document showed DA 3 was in attendance of the inservice training. A review of the facility's document titled, Job Description Dietary Aide, dated December 27, 2021, indicated, .Position Summary: To provide assistance in all dietary functions in accordance with current applicable federal, state, and local standards, guidelines and regulations .The assurance that quality nutritional service are provided on a daily basis and that the dietary department is maintained in a clean, safe and sanitary manner . 5. On December 4, 2023, at 3:01 p.m., an interview with RD1, RD 2, and the CDM was conducted. RD 1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555613 If continuation sheet Page 9 of 17 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 12/06/2023 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)

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated the kitchen wares needed to be placed in the sanitizing solution for 30 seconds in the sanitizer sink. In the other hand, the CDM did not know how long the kitchen wares needed to be placed in the sanitizing solution in the sanitizer sink. RD 2 stated the kitchen wares needed to be placed into the sanitizing solution in the sanitizer sink for 1 (one) minute. RD 1 stated the placing kitchen wares less than the manufacturer's instructions time length could cause for the kitchen wares to be not properly sanitized. RD 1 expectation was for the dietary staff to follow the manufacturer's guidelines time length to place the kitchen wares into the sanitizing solution. According to the USDA Food Code 2022, Section 4-501.114 Manual and Mechanical Ware washing Equipment, Chemical Sanitization -Temperature, pH, Concentration, and Hardness, (C) A quaternary ammonium compound solution shall (2) Have a concentration as specified under § 7-204.11 and as indicated by the manufacturer's use directions included in the labeling. A review of the undated sanitizer manufacturer's use directions for the 3-compartment sink cleaning procedures posted above the 3-compartment sinks, indicated, .Sanitize .Place items in sanitizing solutions for 1 minute . A review of the undated facility's policy and procedure titled, 3-Compartment procedure for manual dishwashing, indicated, .The third compartment is for sanitizing .Immerse all washed items for 1 (one) minute . A review of the facility's document titled, Job Description Consultant Registered Dietitian, revised [DATE], indicated, .Conduct kitchen inspections for safety and sanitation . A review of the facility's document titled, Job Description Dietary Supervisor, dated December 27, 2021, indicated, . Position Summary: To provide assistance in all dietary functions in accordance with current applicable federal, state, and local standards, guidelines and regulations .The assurance that quality nutritional service are provided on a daily basis and that the dietary department is maintained in a clean, safe and sanitary manner . 6. On December 3, 2023, at 10:34 a.m., the two-compartment Prep sinks (sinks used for food production) was observed to have a 10 pound (lb. - a unit of measurement) roast beef defrosting under running water in a 2-inch shallow pan. The roast beef was observed to be partially submerged (about 1/4) into the water. On December 3, 2023, at 10:41 a.m., a concurrent observation of the two-compartment Prep sinks and interview with the CDM was conducted. The CDM verified using a 2-inch shallow pan to defrost a 10-pound roast beef was not the appropriate method. The CDM stated the dietary staff should use a big, deep bowl to fully submerge the roast beef into the water to defrost the meat. On December 4, 2023, at 3:01 p.m., an interview with RD 1 was conducted. RD 1 stated the dietary staff should put the roast beef into a large deep pan fully submerge the meat into the water to properly defrost the meat. RD 1 stated not defrosting meat the right way could cause residents to get sick. RD 1 expectation was for the dietary staff to follow the correct procedures to defrost meat. A review of the facility's policy and procedure titled, Thawing of Meats, revised 2023, indicated . Thawing meat properly .Submerge under running, portable water .with a sufficient pressure to flush away loose particles . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555613 If continuation sheet Page 10 of 17 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 12/06/2023 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure safe, sanitary food preparation and storage practices were followed in the kitchen when: Residents Affected - Many 1. Clean water pitchers were stored on dirty grey plastic shelves; 2. Dust was observed in several kitchen and storage areas, equipment, and ventilation vents; 3. Four rusting silver storage shelves were found in the disposable item storage room; 4. One roast beef was observed defrosting in a shallow two-inch pan; 5. Two Dietary Aides (DA) were observed with their hair not fully covered with hair net; and 6. Several open packages of food items were observed in the walk-in-freezer. These failures had the potential to cause food-borne illnesses in a highly susceptible resident population. Findings: 1. On December 3, 2023, at 10:09 a.m., an observation with the Certified Dietary Manager (CDM) was conducted in the kitchen. One set of grey plastic shelves, where clean water pitchers were stored, showed brown grime on the shelves. During a concurrent interview with the CDM, she stated the grey plastic shelves were dirty. The CDM further stated cross contamination could happen with clean water pitchers stored on the dirty shelves. On December 4, 2023, at 3:01 p.m., during an interview with Registered Dietitian (RD) 1, RD 1 stated clean water pitchers stored on the dirty shelves posed a potential risk for cross contamination. RD 1's expectation was that the shelves used to store clean water pitchers should be clean, with no dust and no dirt accumulated. The facility's policy and procedure titled Sanitation, revised 2023, was reviewed. The policy indiated .all .shelves .shall be kept clean . 2. On December 3, 2023, at 9:14 a.m., an observation of the walk-in refrigerator was conducted with the CDM. There was a cooling ventilator observed mounted under the ceiling, containing two black plastic fan coves on the front, and metal ventilation intake (used to allow air to enter into ventilation spaces) grids on the back. The cooling ventilator wa observed to have accumulation of grey and black debris. During a concurrent interview with the CDM, she stated the grey and black debris on the front and back of the ventilator was dust. The CDM further stated, it was not good to have dust on the cooling ventilator because dust could contaminate food stored in the refrigerator. On December 3, 2023, at 9:23 a.m., an observation of the clean kitchenware storage room was conducted with the CDM. Grey and black debris was observed on the ventilation intake on the ceiling. In addition, the storage shelves, used store clean kitchenware, were covered with brown debris. Durign a concurrent interview, the CDM stated the grey, black, and brown debris was dust. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555613 If continuation sheet Page 11 of 17 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 12/06/2023 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On December 3, 2023, at 9:27 a.m., a kitchen observation was conducted with the CDM. The silver-colored spice holding shelves were observed to have grey and black debris accumulated. In a concurrent interview, the CDM stated the spice storage shelves were covered with dust and were not clean. On December 3, 2023, at 9:37 a.m., a kitchen observation was conducted with CDM. The cart used to store clean baking sheets, clean large plastic containers and plastic lids, was covered with grey particles after the surveyor touched the shelves. During a concurrent interview conducted the CDM stated the cart was dusty. On December 3, 2023, at 9:53 a.m., an observation was conducted with the CDM in the dish washing area. The silver-colored storage shelves, used to store clean kitchenwares, were observed to becovered with black and brown debris. During a concurrent interview with the CDM, the CDM stated the black and brown debris was dust. On December 3, 2023, at 10:25 a.m., an observation of the ice machine was conducted with the CDM. The wall behind the ice machine was covered with grey and black debris. During a concurrent interview, the CDM states the dust should be cleaned. On December 3, 2023, at 10:47 a.m., an observation of the juice area was conducted with the CDM. Thre were open juice boxes on the storage shelves near the juice machine that were sticky. In addition, the shelves were covered with grey and black debris. During a concurrent interview, the CDM stated the shelves should be clean. On December 4, 2023, at 3:01 p.m., an interview was conducted with RD 1. RD 1 stated all areas in the kitchen should be clean and free from dust to prevent cross contamination. The facility's policy and procedure titled, Sanitation, revised 2023, was reviewed. The policy indicated .all .shelves .shall be kept clean . A review of the Federal and Drug Administration (FDA) Food Code 2022, 4-602.13 Nonfood-Contact Surfaces, indicated, .the presence of food debris or dirt on non-food contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests . 3. On December 3, 2023, at 10:25 a.m., an observation of the disposable items storage room was conducted with the CDM. Four silver-colored storage shelves were observed to have brown colored grime. During a concurrent interview, the CDM stated the brown colored grime was rust. The CDM further stated rust on food storage shelves could potentially cause cross contamination, and they needed to be replaced or painted. The facility's policy and procedure titled, Sanitation, revised 2023, was reviewed. The policy indicated .All equipment shall be maintained as necessary and kept in working order .all .shelves .shall remain in good repair and shall be kept clean, free from breaks and corrosion . 4. On December 3, 2023, at 10:34 a.m., a ten-pound (lb- a unit of measurement) roast beef was observed defrosting under running water, in a two-inch shallow pan with only a quarter of the meat submerged into water at the two-compartment sink (sink used for food preparation). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555613 If continuation sheet Page 12 of 17 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 12/06/2023 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On December 3, 2023, at 10:41 a.m., an observation and concurrent interview was conducted with the CDM. The CDM stated the use of a two-inch shallow pan to defrost the ten-pound roast beef was not an appropriate method. The CDM further stated staff should use a big, deep bowl to fully submerge the roast beef into the water to defrost the meat. On December 4, 2023, at 3:01 p.m., an interview was conducted with RD 1. RD 1 stated dietary staff were supposed to put the roast beef into a large, deep pan to fully submerge the meat into water to properly defrost the meat. RD 1 further stated not defrosting meat the right way can cause residents to get sick. RD 1 expected the staff to follow the correct procedures to defrost meat. The facility's policy and procedure titled, Thawing of Meats, revised 2023, was reviewed. The policy indicated, .Thawing meat properly .Submerge under running, portable water .with a sufficient pressure to flush away loose particles . 5. On December 3, 2023, at 11:31 a.m., an observation was conducted with DA 3 in front of the three-compartment sink (three sinks used for cleaning kitchenware, one for washing, one for rinsing and one for sanitizing). DA 3's hair was not fully covered with a hair net. On December 3, 2023, at 12:03 p.m., DA 3 was observed with the CDM at the three-compartment sink. During a concurrent interview, the CDM stated DA 3's hair was not fully covered by hair net. The CDM further stated all hair should be fully covered with a hair net. On December 4, 2023, at 3:01 p.m., an interview was conducted with RD 1. RD 1 stated dietary staff were expected to have their hair fully covered while working in the kitchen since there was potential risk that hair might get into foods and cause cross contamination. RD 1 expected the dietary staff's hair to be fully covered while working in the kitchen. The facility's policy and procedure titled, Dress Code, revised 2023 was reviewed. The policy indicated, .Hat for hair, if hair is short, which completely covers the hair. Hair net for hair if hair is long (over ears or longer) . 6. On December 3, 2023, at 9 a.m., an observation of the walk-in freezer was conducted with the CDM. The following food items were found open without appropriate covering and exposed to air: - One half box of cod; - One half box of turkey franks; and - One box with eight donuts. In a concurrent interview, the CDM stated all opened food items needed to be sealed and stored in airtight containers or bags to prevent freezer burn. On December 4, 2023, at 3:01 p.m., an interview was conducted with RD 1. RD 1 stated opened food items in the freezer needed to be fully covered and sealed to prevent freezer burn. The facility's policy and procedure titled, Procedure for Freezer Storage, revised 2023, was reviewed. The policy indicated, .Store frozen foods in an airtight moisture resistant wrapper .to prevent freezer burn . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555613 If continuation sheet Page 13 of 17 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 12/06/2023 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)

F 0880 Provide and implement an infection prevention and control program. 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 maintain the cleanliness of their reusable equipment, when seven clean oxygen concentrators (a medical device that gives patients extra oxygen) and two Intravenous (IV) poles (a medical device used to hang medicine to administer to patients) were observed partially covered and found in the soiled linen room. Residents Affected - Some This failure had the potential for the transmission of microorganisms from the contaminated linen to residents during the delivery of care. Findings: On December 6, 2023, at 10:31 a.m., an observation of the soiled linen room was conducted with the Housekeeper (HK). There were seven oxygen concentrators observed to be partially covered with plastic bags (top part covered with plastic). In addition, there two IV poles also observed to be partially covered with plastic bags. There was a clean sign taped observed against the wall above the oxygen concentrators and red tape on the floor demarcating the clean area where the equipment was stored. Directly next to the clean equipment were two large open containers with several bags of soiled linens. Across the soiled linen containers is the garbage chute (a passage where garbage is carried to a receptacle at the bottom of a building). In a concurrent interview with the HK, the HK stated the oxygen concentrators were cleaned, covered, and brought into the room. The HK further stated the soiled linen were bagged and brought through the entrance past the clean concentrators, and placed in the soiled linen containers. She stated the garbage was to be brought into the room past the clean oxygen concentrators then disposed of through the garbage chute. On December 6, 2023, at 10:47 a.m., a concurrent observation and interview was conducted with the Director of Nursing (DON) in the soiled linen room. The DON stated the clean oxygen concentrators and IV poles were next to the open soiled linen containers and were partially covered with plastic bags. The DON stated the oxygen concentrators and IV pole should be fully covered with plastic bags after being disinfected. On December 6, 2023, at 3:10 p.m., a concurrent observation and interview was conducted with the Infection Preventionist (IP) in the soiled linen room. The IP stated the oxygen concentrators were partially covered and they should be fully covered. The IP stated the facility did not have a written policy for it. On December 6, 2023, at 5:42 p.m., a concurrent observation and interview was conducted in the soiled linen room with Licensed Vocational Nurse (LVN) 2. LVN 2 stated the oxygen concentrators were not fully covered and there was a potential for contamination with the soiled linen and garbage coming in and out of the room. There was no facility policy for appropriate storing of reusable equipment in relation to infection pevention. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555613 If continuation sheet Page 14 of 17 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 12/06/2023 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm A review of an article titled Care Cleaning and Disinfection of Oxygen Concentrators Between Patients, published by the World Health Organization (WHO - a United [NAME] agency dedicated to global health and safety), dated January 2022, indicated, .Ensure cleaned oxygen concentrator is stored in an area where there is low risk of contamination between uses . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555613 If continuation sheet Page 15 of 17 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 12/06/2023 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)

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and facility document review, the facility failed to follow the policy and procedure to provide an environment free of pests, when fruit flies and one mosquito were observed flying and landing in the kitchen. Residents Affected - Many This failure had the potential to lead to food borne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) in the facility residents who eat food prepared in the kitchen. Findings: On December 3, 2023, at 10:22 a.m., an observation was conducted with the Certified Dietary Manager (CDM) in the kitchen. Six black flies were observed landing on the wall in front of the CDM's office, and two black flies landed in the dish washing area. In a concurrent interview with the CDM, the CDM stated those flies were fruit flies. In addition, the CDM stated it was not OK to have fruit flies or any kind of pests in the kitchen because pests could go onto the food. On December 3, 2023, at 10:24 a.m., during the kitchen observation with the CDM, one fruit fly landed on the wall by the window of the dry storage room. In a concurrent interview, the CDM stated it was another fruit fly. On December 3, 2023, at 10:35 a.m., the CDM and surveyors observed one fruit fly flying around the juice machine. The CDM stated it was a fruit fly. On December 3, 2023, at 10:38 a.m., during a kitchen observation with the CDM, one fruit fly was observed on the wall above the two compartment sink. In a concurrent interview with DA 2, DA 2 described the fruit fly landing above the two-compartment sink as a bug. On December 3, 2023, at 10:54 a.m., during an observation with the CDM in the disposable item storage room, one mosquito was observed flying around. The CDM stated there was a mosquito. On December 4, 2023, at 11:10 a.m., during an observation with the Maintenance Director (MTD), two flies landed above the exit door to the dining area. A concurrent interview the MTD stated those flies were fruit flies. In addition, MTD stated he was not aware there were fruit flies in the kitchen and no staff had reported them to him. On December 4, 2023, at 9:10 a.m., an interview with the Infection Preventionist (IP) was conducted. The IP stated she was not aware of any pest problem in kitchen. The IP's expectation was the kitchen should be pest free, as pests could introduce possible contamination of foods provided to residents. On December 4, 2023, at 9:21 a.m., an interview was conducted with the Administrator (ADM). The ADM stated she was not aware of any fruit flies in the kitchen. The ADM further stated there had been a mosquito issue in the kitchen area a month ago. The ADM's expectation was there should be no pests in the facility. On December 4, 2023, at 3:01 p.m., an interview was conducted with Registered Dietician (RD) 1. RD 1 stated the kitchen was expected to be pest free to prevent cross contamination of residents' (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555613 If continuation sheet Page 16 of 17 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 12/06/2023 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)

F 0925 foods. Level of Harm - Minimal harm or potential for actual harm The facility's policy and procedure titled, Pest Control, revised May 2022, was reviewed. The policy indicated, .It is the policy of this facility to provide an environment free of pests . Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555613 If continuation sheet Page 17 of 17