Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Grove Care And Wellness during CMS and state inspections, most recent first.
A resident with serious infections reported that an RN who checked her IV line and administered medication smelled of alcohol and behaved arrogantly, and stated that no one followed up with her about this concern. The Administrator, serving as Grievance Officer, and the DON were informed of the allegation and spoke with the RN and some staff, but did not interview the resident or other residents. An LVN completed a change of condition form and care plan characterizing the complaint as false allegations, based on instructions from the DON, without speaking to the resident or the RN. This response did not follow the facility’s grievance policy requiring prompt, thorough investigation and direct acknowledgment to the individual expressing the concern.
Surveyors observed that staff failed to follow contact isolation and hand hygiene protocols while serving meals to two residents sharing a room posted for contact isolation. A CNA entered the room, wore only gloves (no gown) to deliver a meal tray to a resident on contact isolation for MRSA, then removed the gloves and immediately delivered a second tray to the other resident without performing hand hygiene. The CNA later acknowledged she should have worn gown and gloves and used hand hygiene, and the IP confirmed this. Facility policies required gown and gloves for contact precautions, donning PPE before room entry, changing PPE before caring for another resident, and performing hand hygiene after glove removal, before and after entering isolation settings, and before and after assisting with meals, but these practices were not followed.
A resident with osteomyelitis and osteoporosis sustained a rib fracture, but the facility failed to develop a care plan to address this condition. Despite the change in condition being noted and an X-ray ordered, no care plan was initiated, as confirmed by the LVN and DON. The facility's policy requires a comprehensive care plan for each resident, but this was not followed, leaving staff without guidance for appropriate interventions.
The facility failed to maintain safe food storage and handling practices. Lettuce and celery were improperly stored in unsealed bags, and a container of macaroni was undated and unlabeled. Additionally, a dietary aide improperly stacked containers, leading to potential contamination of cut watermelon. These actions violated the facility's policies on food storage and preparation.
A facility failed to develop a care plan for a resident's Dexcom blood glucose monitoring device, leading to potential delays in insulin administration. The resident, diagnosed with diabetes mellitus, had a physician order for the device, but no care plan was in place. The DON confirmed the oversight, which contradicted the facility's policy requiring a care plan within 48 hours of admission.
The facility failed to follow physician orders for two residents with diabetes and hypertension. A resident's blood sugar reached 500 without notifying the physician, and another resident's blood sugar was 442 without documentation of physician contact. Additionally, a resident's blood pressure was not monitored before administering Lisinopril on multiple occasions, contrary to physician orders.
A facility failed to properly document the administration and wasting of controlled substances for a resident, leading to discrepancies in medication records. The resident had a prescription for Norco, but the medication was not consistently documented on the MAR, and a wasted dose lacked a second nurse's witness. The DON confirmed these issues, emphasizing the importance of accurate documentation to prevent diversion.
A facility failed to ensure the Consultant Pharmacist identified and reported irregularities during the monthly medication regimen review for a resident who received sertraline without appropriate indication. The resident's sertraline prescription was changed from depression to chronic pain without documented clinical justification, and the CP did not report this change during three separate MRRs. The Director of Nursing confirmed the lack of documentation and acknowledged the oversight.
A resident was administered sertraline without appropriate clinical justification, as the indication was changed from depression to chronic pain without documentation. The facility's process for psychotropic medication administration and monitoring was not followed, leading to unnecessary medication use.
A CNA failed to perform hand hygiene before and after distributing lunch trays, as observed by surveyors. The CNA admitted to not washing or sanitizing hands, which was confirmed by the IP as a requirement per the facility's Hand Hygiene policy. The policy mandates hand hygiene before and after handling food and assisting residents with meals.
A facility failed to report an abuse incident between two residents to the State Agency within the required two-hour timeframe. The incident involved a resident pushing another during an argument, with no injuries sustained. The LVN and CNA delayed reporting the incident to the Administrator, who then reported it to the State Agency later than required by regulations.
A resident's pressure injury on the sacral area was not identified upon admission, and treatment orders were delayed. The Treatment Nurse failed to document the wound initially, and the facility's protocol for pressure injury prevention was not followed. The Director of Nursing confirmed the absence of a wound care consult order. Medical records showed discrepancies in treatment administration, and staff interviews revealed lapses in assessment and documentation. The facility's policies were not adhered to, impacting the resident's care.
A resident with a history of diabetes and a left foot amputation experienced hallucinations and increasing confusion, which were not addressed by the facility. Despite a care plan to monitor for delirium, no documentation or care plan updates were made, leading to the resident's transfer to a hospital. The RN acknowledged the oversight, and the facility's policy on change of condition reporting was not followed.
Failure to Investigate Resident Grievance About RN Alcohol Odor
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and thoroughly investigate a resident’s complaint that an RN smelled of alcohol while providing care. Resident A, admitted with osteomyelitis, bacteremia, and MRSA, reported that a male nurse who checked her IV line and gave her medication had alcohol on his breath and acted arrogantly. She stated she told another employee about the alcohol smell and that no one came to talk with her about the incident. A Change in Condition Evaluation dated March 8, 2026, documented “false allegation towards staff and falsifying stories” and “resident having false accusations,” but there was no indication that Resident A was interviewed about her concern. The Administrator, who is the facility’s Grievance Officer, stated that the DON informed him of Resident A’s concern that the RN smelled of alcohol while beginning her IV procedure. He stated he spoke with the RN, who denied using alcohol, and with an LVN who reported she did not smell alcohol on the RN, and he interviewed other staff working with the RN that evening. However, he acknowledged he did not interview Resident A or other residents regarding the incident, despite facility policy requiring the Grievance Official to evaluate and investigate concerns, take immediate action, and respond to the individual expressing the concern within three working days. LVN 2 reported that, after being notified of the allegation during report, she contacted the DON and was instructed to complete a change of condition form and write a care plan about false allegations; she stated she did not talk with the RN or Resident A and wrote what the DON told her to write. The facility’s grievance policy requires a process that allows residents to voice concerns without fear of reprisal, prompt efforts to resolve grievances, and investigation and acknowledgment by the Grievance Official, which did not occur in this case.
Failure to Follow Contact Isolation and Hand Hygiene Protocols During Meal Service
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of transmission-based precautions for residents on contact isolation. During an unannounced infection prevention and control investigation, the Infection Preventionist (IP) reported that several residents were on enhanced barrier precautions and a few on contact isolation. Later observation showed a CNA entering the shared room of two residents with a sign on the door indicating contact isolation. The CNA donned only gloves to deliver a meal tray to one resident, then removed the gloves, took another meal tray from a CNA in the hallway, and delivered it to the other resident without donning a gown at any time and without performing hand hygiene between caring for the two residents. The CNA stated that only one of the two residents was on contact isolation and acknowledged she should have worn a gown and gloves when serving that resident’s meal tray and should have performed hand hygiene before assisting the other resident. The IP confirmed that the CNA should have followed proper infection prevention and control protocol by wearing a gown and gloves for the resident on contact isolation and performing hand hygiene before assisting the second resident. Record review showed that the first resident had osteomyelitis, bacteremia, and MRSA, with a physician’s order for contact isolation. Facility policies on transmission-based precautions, infection prevention and control, and hand hygiene required staff to don gown and gloves for contact precautions, don PPE before room entry and remove it before exit, change PPE before caring for another resident, and perform hand hygiene after removing gloves, before and after entering isolation settings, and before and after assisting a resident with meals. These requirements were not followed during the observed meal service.
Failure to Develop Care Plan for Resident's Rib Fracture
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who sustained a rib fracture, which was identified as a deficiency during an unannounced visit. The resident, who was admitted with osteomyelitis and osteoporosis, was found to have acute fractures to the right ribs. Despite the change in condition being noted and an X-ray ordered, there was no documented evidence that a care plan was initiated to address the rib fracture. This oversight was confirmed during interviews with the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), who both acknowledged that a care plan should have been created immediately upon identification of the fracture. The facility's policy on Comprehensive Person-Centered Care Planning requires the interdisciplinary team to develop a care plan with measurable objectives and timeframes for each resident's needs. However, in this case, the licensed nurses did not initiate a care plan for the resident's rib fracture, which was a communication tool expected to guide treatment and interventions. The lack of a care plan meant that the staff was not guided in providing appropriate interventions tailored to the resident's needs, as highlighted by the LVN and DON during the investigation.
Deficiencies in Food Storage and Handling Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food practices, as observed during a kitchen tour and subsequent interviews. Lettuce and celery were found in unsealed plastic bags, exposed to air in the walk-in refrigerator, contrary to the facility's policy that requires such produce to be stored in sealed bags or containers to maintain freshness. Additionally, a small container of elbow macaroni in the dry storage area was undated and unlabeled, violating the facility's policy that mandates all food items to be labeled and dated for safety and product rotation. Further observations revealed improper handling of food items, where a dietary aide was seen stacking a tin container with whole fruit on top of another container containing cut watermelon, resulting in direct contact and potential contamination. The Certified Dietary Manager confirmed that the watermelon was contaminated and needed to be discarded, as per the facility's policy on food preparation, which emphasizes preventing cross-contamination by keeping raw and cooked foods separate and using sanitized utensils.
Failure to Develop Care Plan for Blood Glucose Monitoring Device
Penalty
Summary
The facility failed to develop and implement a care plan for a resident's personal blood glucose monitoring device, specifically a Dexcom monitor. This deficiency was identified through observation, interview, and record review. On January 28, 2025, the resident was observed at the nurse's station attempting to alert the nursing staff due to an increase in blood sugar levels indicated by the Dexcom monitor. The following day, the resident reported that the nursing staff would not administer insulin until a licensed nurse performed a blood sugar check, despite the Dexcom device alarming for high blood sugar levels. The resident, who was admitted with a diagnosis of diabetes mellitus, had a physician order for the use of the Dexcom G7 Sensor to monitor blood sugar levels, with instructions to change the sensor every 10 days. However, there was no care plan in place to address the use of this device. The Director of Nursing confirmed the absence of a care plan and acknowledged that one should have been developed. The facility's policy requires a comprehensive person-centered care plan to be developed within 48 hours of admission, which was not adhered to in this case.
Failure to Follow Physician Orders for Diabetes and Hypertension Management
Penalty
Summary
The facility failed to provide care and treatment according to physician orders and the plan of care for two residents, leading to deficiencies in managing their diabetes and hypertension. Resident 14, who has diabetes mellitus, experienced an increase in blood sugar levels as indicated by his personal Dexcom monitor. Despite showing the staff his monitor, the licensed nursing staff delayed administering insulin until they performed their own blood sugar check. Additionally, on January 14, 2025, Resident 14's blood sugar level reached 500, but there was no notification to the physician as required by the physician's order. Similarly, Resident 286, also diagnosed with diabetes mellitus, had a blood sugar level of 442 on January 23, 2025, which was above the threshold requiring physician notification. However, there was no documented evidence that the physician was informed of this critical level. The Director of Nursing confirmed that the physician should have been contacted in both cases when the blood sugar levels exceeded the specified parameters. Furthermore, the facility failed to monitor Resident 14's blood pressure before administering Lisinopril, a medication for hypertension, on multiple occasions throughout January 2025. The physician's order specified that the medication should be held if the systolic blood pressure was less than 110, but the facility did not document any blood pressure readings before administering the medication on 18 different days. This oversight could lead to adverse effects if the medication was given when the blood pressure was below the safe threshold.
Controlled Substance Documentation Deficiency
Penalty
Summary
The facility failed to ensure proper documentation and administration of controlled substances for Resident 18, leading to discrepancies in medication records. Resident 18 had a physician's order for hydrocodone-acetaminophen (Norco) to be administered as needed for severe pain. However, during a medication cart inspection, it was found that the Norco was signed out from the Controlled Medication Count Sheet but not documented on the Medication Administration Records (MAR) as administered on several occasions. Specifically, the medication was unaccounted for on five different dates in November and December 2024. Additionally, there was a failure to follow the facility's policy for wasting controlled substances. On December 21, 2024, a Norco tablet was wasted without the required documentation of a second nurse's witness on the Count Sheet. The Director of Nursing confirmed these discrepancies and acknowledged the importance of proper documentation to prevent medication diversion and ensure accurate administration. The facility's policies clearly outlined the need for immediate documentation on the MAR and the requirement for two licensed nurses to witness and document the destruction of unused controlled substances.
Failure to Identify and Report Medication Irregularities
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported irregularities during the monthly medication regimen review (MRR) for a resident who received sertraline without appropriate indication or clinical justification. The resident, who had a history of major depressive disorder, was initially prescribed sertraline for depression. However, the indication was changed to chronic pain without documented clinical justification. The CP did not identify or report this change during the MRRs conducted on three separate occasions. The Director of Nursing (DON) confirmed the absence of documentation for the new indication and acknowledged that the CP should have identified and reported the irregularity. The facility's policy required the MRR to include identification of irregularities and unnecessary drug use, but this was not adhered to in the case of the resident's sertraline prescription. The CP admitted to not identifying or reporting the change in indication, which was a deviation from the established MRR process.
Unjustified Use of Sertraline for Chronic Pain
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications, specifically sertraline, which was administered without appropriate indication or clinical justification. The resident, who had a diagnosis of major depressive disorder, was initially prescribed sertraline for depression. However, the indication for the medication was changed to chronic pain without documented clinical justification. The Director of Nursing (DON) and the Social Services Director (SSD) confirmed that there was no documentation in the resident's medical record to justify the change in indication for sertraline from depression to chronic pain. The facility's process for psychotropic medication administration and monitoring was not followed, as there was no clear indication or documented clinical justification for the use of sertraline for chronic pain. The SSD also noted that there was no initial psychiatric assessment conducted upon the resident's readmission, and the Interdisciplinary Team did not discuss the change in medication indication. The facility's policy required that psychotropic medications be prescribed to treat a specific diagnosed condition, with appropriate documentation in the clinical record. The lack of documentation and failure to follow the facility's policy resulted in the administration of unnecessary medication, increasing the potential for medication interactions and adverse reactions for the resident.
Inadequate Hand Hygiene During Meal Distribution
Penalty
Summary
The facility failed to ensure proper infection control practices were followed when a Certified Nursing Assistant (CNA) was observed not performing hand hygiene before and after distributing lunch trays. On January 29, 2025, at 11:48 a.m., the CNA was seen passing out lunch trays without washing or sanitizing his hands. During an interview at 12:00 p.m. the same day, the CNA acknowledged that he should have washed and sanitized his hands prior to touching the lunch tray and after placing the tray with the resident. On January 30, 2025, at 10:23 a.m., the Infection Preventionist (IP) confirmed that staff should wash or sanitize their hands before and after handling each tray and after every three residents during meal distribution. A review of the facility's Hand Hygiene policy from 2023 indicated that staff should use an alcohol-based hand rub containing at least 62% alcohol or soap and water before and after direct contact with residents, entering isolation precaution settings, eating or handling food, and assisting a resident with meals.
Failure to Timely Report Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency within the required two-hour timeframe. This incident involved two residents, where one resident pushed another during an argument by the elevator door. The incident occurred at 4:00 a.m., and although the involved resident did not sustain injuries, the altercation was not reported promptly as required by regulations. The Licensed Vocational Nurse (LVN) and Certified Nursing Assistant (CNA) who were aware of the incident did not report it to the Administrator immediately. The LVN reported the incident to the Administrator at around 7:00 a.m., and the CNA reported it approximately three hours after the incident occurred. The Administrator was informed of the incident at around 9:00 a.m. and subsequently reported it to the State Agency via facsimile about an hour later. The facility's policy requires that such incidents be reported to the appropriate authorities within two hours, which was not adhered to in this case.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to provide timely and necessary treatment for a pressure injury on a resident's sacral area. Upon admission, the pressure injury was not identified, and treatment orders were not initiated promptly. The Treatment Nurse (TN) admitted that the wound was difficult to notice due to the resident's dark skin tone and loose skin, and she forgot to document the wound in the initial skin assessment. The facility's protocol for pressure injury prevention, which includes a wound consult, was not followed as no wound consultant was involved. The Director of Nursing (DON) confirmed that there was no order for a wound care consult upon identifying the pressure injuries. The resident's medical records showed discrepancies in the documentation and administration of treatment orders. Treatments scheduled for specific dates were documented as administered days later, indicating a delay in care. The resident's progress notes revealed a worsening condition, with a foul odor and purulent exudate noted, leading to the resident's transfer to a hospital. Interviews with various staff members, including the Licensed Vocational Nurse (LVN), Minimal Data Set (MDS) nurse, and Registered Nurse (RN), highlighted lapses in the initial assessment and documentation process. The RN admitted to forgetting to document the sacral pressure injury on the initial assessment, and the MDS nurse did not complete the wound care notes due to a lack of confidence. The facility's policies on change of condition reporting and skin management were not adhered to, contributing to the delay in treatment and potential impact on the resident's healing process.
Failure to Address Change in Cognitive Status
Penalty
Summary
The facility failed to address a change in cognitive status for Resident A, who exhibited hallucinations and increasing confusion. Resident A, admitted with a left foot amputation and diabetes mellitus, had a BIMS score indicating moderate cognitive intactness. Despite episodes of confusion and an elevated white blood cell count, there was no documented evidence of hallucinations initially. However, Resident A's care plan included monitoring for signs of delirium and changes in behavior. On October 13, 2024, Resident A was noted to be confused, experiencing hallucinations, and was subsequently transferred to a hospital. Interviews and record reviews revealed that Resident A's condition deteriorated over three days, with hallucinations and tremors observed by a roommate and staff. The RN confirmed that Resident A was hallucinating and confused, but no change of condition was documented, and no SBAR form was completed. The facility's policy required timely communication of changes in resident condition to the physician, documentation in progress notes, and updates to the care plan, which were not followed in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Riverside
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Riverside Behavioral Healthcare Center | 1.2 mi | ★★★★★ | 15 | 0 |
| Community Care On Palm | 1.3 mi | ★★★★★ | 15 | 0 |
| Community Care And Rehabilitation Center | 2.4 mi | ★★★★★ | 4 | 0 |
| Valencia Gardens Health Care Center | 2.9 mi | ★★★★★ | 0 | 0 |
| Vista Pacifica Center | 3.2 mi | ★★★★★ | 0 | 0 |
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