Citrus Grove Post Acute

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

LVN 2 mentioned that skin condition updates should align with appropriate treatments and reflect the current skin status. Additionally, LVN 2 observed that the weekly summaries and daily documentation for sampled residents did not accurately reflect their skin conditions.On July 30, 2025, at 2:53 p.m. an interview was conducted with the Assistant Director of Nursing (ADON), and The ADON stated the following:a. The nurses were expected to document the wounds and the current skin status;b. The physician's orders should reflect the wounds;c. The daily and weekly documentation should reflect the current skin conditions as indicated in the skin sections of the assessments. d. There was a risk for residents not to receive accurate assessments, treatments, changes and monitoring of the skin if the current skin conditions were not reflected in the nurses' charting, which could cause a change or worsening of a skin condition.e. The nurses should be charting to match the current conditions with full head to toe assessments that accurately reflect the conditions of the resident which included the skin. f. All nurses are provided with training for skin care competencies and should provide the services according to the training received.A review of the facility document titled, Licensed nurse orientation checklist (Licensed Nurse Training module), undated, indicated, .Skin Delivery Care Process.skin assessment (upon admission then weekly x 4) .skin care plan with revision, review, resolve.pressure injury staging guide.wound terminology guide.weekly wound MD rounds and recommendations.writing orders for skin problems/wound.A review of the facility policy and procedure titled, Nursing Documentation dated, June 2022, indicated, .Purpose.to communicate patient's status and provide complete, comprehensive, and accessible accounting of care and monitoring provided.documentation.clear, concise, pertinent, and accurate based on the resident's/patient's condition, situation, and complexity.nursing assessment and interventions.evaluation of the patient's outcomes.

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Citrus Grove Post Acute

9025 Colorado Avenue Riverside, CA 92503

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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

bed mobility-non-restraint.The Bed safety assessment dated August 1, 2023, indicated, .Res currently has one quarter x 2 rails for mobility and positioning.A review of Resident 6's assessments indicated no documentation of an ongoing assessment and evaluation for the use of side rails.On August 15, 2025, at 1:18 p.m. an interview and record review were conducted with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). A review of the Bed Rail policy was conducted along with a full

review of the sampled resident bed rail assessments for Residents 1, 2, 5 and 6. The ADON stated the current policy for bed rails was updated as of February of 2025. The ADON stated the process regarding bed rails was that upon admission a bed rail evaluation would indicate the use of the rails as enablers for mobility and should have an MD order, consent for use, and appropriate according to the manufacturer's specifications. The ADON stated the bed rail evaluation would be done during a change in condition and

during the quarterly IDT meetings. The ADON indicated the previous policy was for the bed rails to be reviewed quarterly but that there were new annual changes to that protocol that were not indicated in the policy.A concurrent record review with the ADON for Resident 1 was conducted. The ADON stated Resident 1 did not have a bed rail assessment since 2023 and should have to determine the need and safety for use of bed rails. The ADON stated the side rails were not discussed in the IDT meeting after the fall that occurred on July 14, 2025, and should have been. The ADON stated, The side rails were not in the right position which would have placed the resident at risk for a fall during that time when the fall occurred.

The ADON stated there was a potential for a fall if the side rails were not in the proper position. Further

review of the bed rail assessments was conducted for Residents 2, 5 and 6 were conducted with the ADON. The ADON further stated Residents 1, 2, 5 and 6 did not have updated bed rail assessments since 2023 and the care plans for the use of side rails were not updated to reflect the current use of the side rails and they should have to prevent the risk of falls and injury.A review of the facility policy titled Bed Rails dated February 21, 2025 indicated, .Bed rails.utilize a person-centered approach when determining the use of bed rails.variety of types one-half, one quarter.bed rails, side rails, safety rails, grab bars and assist bars.as part of the comprehensive assessment, the IDT will review and determine the residents needs, and whether or not the use of bed rails meets those needs.acute medical or surgical interventions.risk for falling.the facility will continue to provide necessary treatment and care to the resident who has bed rails in accordance with professional standards of practice.

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