F 0609
Level of Harm - Minimal harm
or potential for actual harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
Based on observation, interview, and record review, the facility failed to report an allegation of abuse to the
State Agency (SA) as required within two hours, for one of two residents reviewed (Resident 2).
Residents Affected - Few
This failure had the potential to put residents at risk for further abuse.
Findings:
On January 17, 2025, at 8:30 a.m., an unannounced visit was made to the facility for an allegation of
abuse.
On January 17, 2025, at 9:23 a.m., an observation with a concurrent interview was conducted with
Resident 2. Resident 2 was in his room, alert, and interviewable. Resident 2 stated he had an incident with
Resident 1, he did not recall the date, but it was around 4:00 a.m. Resident 2 stated he had an argument
with Resident 1 and he pushed him on the arm by the elevator door. Resident 2 stated he did not sustain
injuries.
On January 17, 2025, Resident 2 ' s record was reviewed. Resident 2 was admitted to the facility on , with
diagnoses including urinary tract infection, unspecified heart failure, other acute kidney failure, Klebsiella
Pneumoniae, other symptoms and signs concerning food and fluid intake, chronic idiopathic constipation,
Type 2 Diabetes Mellitus without complications, other abnormalities of gait and mobility, and need for
assistance with personal care.
The progress notes dated, January 2, 2025 indicated Resident 2 had an altercation with Resident 1 on
January 2, 2025 at 4:00 a.m.
On January 17, 2025, at 4:33 p.m., an interview was conducted with Licensed Vocational Nurse (LVN) 1.
LVN 1 stated on January 2, 2025, at around 4:00 a.m., he heard the yelling between Resident 1 and 2 but
he did not actually witness the incident. LVN 1 stated Resident 2 was already on the floor by the time he
arrived on the scene. LVN 1 stated he reported the incident to the Administrator on January 2, 2025, at
around 7:00 a.m. LVN 1 stated he should have reported the incident to the Administrator immediately.
On January 17, 2025, at 4:48 p.m., an interview was conducted with Certified Nursing Assistant (CNA) 1.
CNA 1 stated she worked on January 2, 2025, and at around 4:00 a.m., she had witnessed the incident
between Residents 1 and 2. CNA 1 stated she had reported the incident to LVN 1, who was already present
by then. CNA 1 stated she also reported it to the Administrator around three hours later
(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
01/17/2025
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 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
from the time the incident had occurred. CNA 1 stated the incident should have been reported within two
hours.
On January 22, 2025, at 8:33 a.m., an interview was conducted with the Administrator. The Administrator
stated the incident between Residents 1 and 2 was reported to him on January 2, 2025, at around 9:00
a.m., the Administrator stated the incident was reported to the SA via facsimile about an hour or so. The
Administrator stated the incident between Residents 1 and 2 should have been reported to the SA within
two hours. The Administrator further stated facility staff should be able to report abuse incidents to the SA
via phone call or fax the completed SOC 341 (form used to report allegations of abuse to the elderly). The
Administrator stated instructions on how to report an abuse is available at the nursing station.
The facility ' s policy and procedure titled, Abuse: Prevention of and Prohibition Against, dated November
28, 2017, indicated, .each resident has the right to be free from abuse .the Facility will provide oversight
and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that
promotes and respects the rights of the residents to be from abuse .allegations of abuse .will be reported
outside the Facility and to the appropriate State or Federal agencies in the applicable timeframes, as per
this policy and applicable regulations .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555613
If continuation sheet
Page 2 of 2
