Health inspection·November 4, 2024

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 interview and record review the facility failed to ensure a change in cognitive status was addressed, for one of three residents reviewed (Resident A), when Resident A exhibited hallucinations (a perception of having seen, heard, touched, tasted, or smelled something that wasn't actually there) and increasing confusion. In a addition, there was no plan of care developed to address Resident A's hallucinations and confusion. Residents Affected - Few This failure resulted in a delay in the care and treatment for Resident A when the resident was transferred to the general acute hospital three days after onset of hallucinations and increasing confusion. Findings: On November 1, 2024, at 9:30 a.m., an unannounced visit to the facility was conducted to investigate a complaint. On November 1, 2024, a review of Resident A ' s medical record was conducted. Resident A was admitted to the facility on [DATE], with diagnoses which included a left foot amputation and diabetes mellitus (abnormal blood sugar). A review of Resident A's Minimum Data Set (MDS - an assessment tool), dated October 7, 2024, indicated Resident A had a BIMS (Brief Interview of Mental Status) score of 11 (moderate cognitively intact). A review of Resident A's Progress Notes, indicated Resident A had episodes of confusion on October 7 to 12, 2024, and was started on antibiotic (medication to treat infection) due to elevated white blood cell count (WBC - found in the blood, part of the body ' s immune system, helps fight infections) . There was no documented evidence Resident A exhibited hallucinations on October 7 to 12, 2024. A review of Resident A ' s care plan, dated October 7, 2024, indicated, Resident A .has elevated WBC 16.7 (normal range 4.5 to 11) .interventions .Monitor/document/report to MD (medical doctor) s/sx (signs and symptoms) of delirium (serious disturbance in mental abilities resulting in confused thinking and reduced mental awareness); changes in behavior, altered mental status, wide variation in cognitive functions throughout the day, communication decline, disorientation, periods of lethargy (lack of energy), restlessness and agitation, altered sleep cycle . A review of Resident A's Progress Notes, dated October 13, 2024, at 11:47 a.m., indicated .patient is alert and verbally responsive .patient had increase confusion saying he seen his wife in the (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 2 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 11/04/2024 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)