Health inspection·November 13, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 necessary treatment and services to promote healing of pressure injuries (a localized area of skin damage caused by prolonged or intense pressure on the skin, often over bony parts of the body) are provided in a timely manner, for one of three residents (Resident A), when: Residents Affected - Few - The pressure injury on the sacral area (lower portion of spinal column) was not identified on admission and treatment orders not initiated timely; and - Treatment orders were not administered as ordered by the physician. These failures had the potential in the delay in care and treatment of Resident A's pressure injury which could affect healing. Findings: On November 6, 2024, at 12: 30 p.m., an unannounced visit to the facility was conducted to investigate complaints and facility reported incident of quality of care and neglect. On November 6, 2024, at 1:30p.m., an interview and concurrent record review was conducted with the Treatment Nurse (TN). The TN stated when Resident A was admitted to the facility, it was hard to notice the wound on the resident's sacrum, due to the resident ' s dark skin tone. The TN stated Resident A came from the hospital with a scaral wound which was unable to stage because of presence of necrotic tissue (black dead tissue) and was difficult to see and took two people to examine her sacral area because the resident had loose skin around her bottom, it. The TN stated she forgot to document a description of the sacral wound bed on Resident A's skin assessment note, dated October 22, 2024. The TN stated Resident A's sacral wound bed had an eschar (dark colored leathery dead tissue) present when she assessed it on October 15, 2024. The TN stated the facility's protocol for prevention of pressure injury which includes a wound consult. The TN stated usually a wound consultant comes in and would document an assessment of the wound weekly and would give any treatment recommendations for the licensed nurse to implement, but there was no wound consult done. The TN stated she last worked on October 29, 2024, and returned to work on November 5, 2024. On November 6, 2024, at 4:00 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated Resident A did not have an order for a wound care consult upon identification of the pressure injuries. The DON stated but Resident A did not see a wound care consultant. On November 6, 2024, a review of Resident A ' s medical record was conducted. Resident A was (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 4 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 11/13/2024 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)