Complaint Investigation

Citrus Grove Post Acute

December 31, 2025 · Riverside, CA · 9025 Colorado Avenue

Citations 1

CMS Rating 3/5

Beds 120

Provider ID 056315

Healthcare Facility

Citrus Grove Post Acute

Riverside, CA · View full profile →

Source Document

Official CMS Inspection Report (Medicare.gov)

Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.

Inspection Summary

CITRUS GROVE POST ACUTE in RIVERSIDE, CA — inspection on December 31, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0627

Resident Rights Deficiencies

BDD stated that he was working with the facility for Resident 1's placement.

The BDD stated he

telephone interview was conducted with the Enhanced Case Manager (ECM) with the [name of

and personalized support.

The ECM stated that he was assisting the facility with a safe discharge for Resident 1.

The ECM stated that Resident 1 did not meet the criteria for room and board placement because Resident 1 was unable to perform activities of daily living without assistance.

The ECM stated that Resident 1 was discharged from the facility on December 17, 2025.On December 31, 2025, at 2:31 p.m., an interview was conducted with the facility's Director of Nursing, (DON).

The DON stated the room and board manager should assess the resident in person prior to discharge and social services should arrange the discharge after acceptance. On January 13, 2026, at 2:01 p.m., an interview was conducted with the Administrator (Adm) and the Interdisciplinary Team (DON, SSD, and Physical Therapist). -The Adm stated a resident could be discharged to a room and board if they were high functioning, meaning the resident could perform most activities independently;-The SSD stated she provided the third-party representative with a packet for Resident 1 which included a face sheet, physician order, and the physician's History and Physical.

The SSD further stated Resident 1 is wheelchair bound; and-The Adm stated facility staff did not assess the discharge location for Resident 1.A record of Resident 1's Discharge Plan Documentation dated December 17, 2025, indicated .3.

Discharge Location.3a.

Other destination Room and Board.BB.1.

Transportation for Discharge a. W/C [wheelchair] Van.Durable Medical Equipment.15a. wheelchair.D1.

Assistance Level

Bed Mobility [a person's ability to move and reposition themselves while in bed, including rolling,

scooting, sitting up from lying down, and lying down from sitting] .2.

Needs Assistance .1b.

Toileting.2.

Needs Assistance.2.

Household tasks (meal prep, bill paying, simple cleaning) .2.

Needs Assistance.3.

Transfers from bed/chair.2.

Needs Assistance .4.

Walking .3.

Dependent.A review of Resident 1's Progress Notes dated December 16, 2025, at 2:04 p.m., indicated SSD received a call from [name of BDD] who states he was able to find resident room and board placement and has it all arranged for him to discharge tomorrow morning 12/17/25.A review of Resident 1's Order Summary Report dated December 16, 2025, indicated .Resident may DC on 12/17/2025.A review of the packet sent to the third-party representative for the RABM included Resident 1's face sheet, the physician's H&P, and the physician orders.

There was no documentation of Resident 1's functional, or ADL status was included in the packet sent to the third-party representative. On January 14, 2026, at 1:43 p.m., an interview was conducted with the SSD, she stated she did not follow-up with the RABM after becoming aware of Resident 1's placement. A review of the facility's policy and procedure titled Discharge Summary and Plan revised December 2016, indicated .10.

Residents transferring to another skilled nursing facility, or who are discharged to a home health agency, long-term care hospital, or inpatient rehabilitation facility will be assisted in selecting a post-acute care provider that is relevant and applicable to the resident's goals of care and treatment preferences.

Frequently Asked Questions

What is an F-tag violation?

F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.

Were these violations corrected?

Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.

How often do nursing home inspections happen?

CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.

What should families do about these violations?

Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in RIVERSIDE, CA, (5) Report new concerns to state authorities.

Where can I see the full inspection report?

Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from CITRUS GROVE POST ACUTE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.

More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.