Cycle 1
Health 2025-01-30 · Fire 2025-01-30
8 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Riverside, CA
The Grove Care And Wellness
5-star overall rating with 4-star inspections with 8 recent health deficiencies
3401 Lemon Street, Riverside, CA
(951) 686-8202
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
38
Certified beds
Average residents
35
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1994-07-30
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.63
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.33
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.61
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.56
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.96
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
4.02
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.53
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.27
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.66
CMS adjusted RN staffing hours
Adjusted total hours
4.75
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
30%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,764
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.68
Composite VBP score used to determine payment impact.
Payment multiplier
0.9917
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.95
Baseline 20.05% · Performance 20.99% · Measure score 0.95 · Achievement 0.95 · Improvement 0
Healthcare-associated infections
2.54
Baseline 6.72% · Performance 7.07% · Measure score 2.54 · Achievement 2.54 · Improvement 0
Total nurse turnover
9.14
Baseline 34.29% · Performance 26.32% · Measure score 9.14 · Achievement 9.14 · Improvement 7.95
Adjusted total nurse staffing
2.84
Baseline 3.77 hours · Performance 3.88 hours · Measure score 2.84 · Achievement 2.84 · Improvement 0.05
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.29% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 105 · Observed rate 6.67% · Lower 95% interval 6.54% |
| Discharge to community | 70.08% |
50.57%
19.5 pts better
|
Better than the National Rate · Eligible stays 98 · Observed rate 68.37% · Lower 95% interval 59.78% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 69 · Denominator 69 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 69 |
| Discharge self-care score | 35.29% |
53.69%
18.4 pts worse
|
Numerator 12 · Denominator 34 |
| Discharge mobility score | 52.94% |
50.94%
2 pts better
|
Numerator 18 · Denominator 34 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 69 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.07% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 59 · Observed rate 6.78% · Lower 95% interval 4.18% |
| Staff COVID-19 vaccination coverage | 11.96% |
8.2%
3.8 pts better
|
Numerator 11 · Denominator 92 |
| Staff flu vaccination coverage | 36.43% |
42%
5.6 pts worse
|
Numerator 47 · Denominator 129 |
| Discharge function score | 64.71% |
56.45%
8.3 pts better
|
Numerator 22 · Denominator 34 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 97.96% |
96.28%
1.7 pts better
|
Numerator 48 · Denominator 49 |
| Resident COVID-19 vaccinations up to date | 14.71% |
25.2%
10.5 pts worse
|
Numerator 5 · Denominator 34 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
98.5%
1.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
1.6%
1.6 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.0% |
6.8%
2.8 pts better
|
11.4%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.0% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
4.1%
4.1 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.7% |
13.7%
7 pts worse
|
19.6%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.7% |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.6% |
10.7%
7.1 pts better
|
14.9%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 5.6% |
1.0%
4.6 pts worse
|
1.0%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.1% |
10.9%
18.2 pts worse
|
19.8%
9.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 29.1% |
| Percentage of long-stay residents with pressure ulcers | 14.7% |
4.7%
10 pts worse
|
5.1%
9.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.0%
6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.5% |
11.2%
1.7 pts better
|
12.0%
2.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.5% · Observed 10.8% · Expected 12.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.5%
1.3 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.9% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.2% |
93.2%
1 pts better
|
79.7%
14.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.9% |
23.2%
7.3 pts better
|
23.9%
8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.9% · Observed 18.5% · Expected 27.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-06 · Fire 2023-12-06
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Cycle 3
Health 2022-11-04 · Fire 2022-11-04
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-12-06
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-12-13
F · Potential for more than minimal harm
2022-11-04
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-11-28
D · Potential for more than minimal harm
2022-11-04
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-11-28
D · Potential for more than minimal harm
2022-11-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-28
D · Potential for more than minimal harm
2022-11-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-11-28
D · Potential for more than minimal harm
2022-11-04
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2022-11-28
D · Potential for more than minimal harm
2022-11-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-28
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-03-25
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-04-01
E · Potential for more than minimal harm
2025-01-30
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-02-12
D · Potential for more than minimal harm
2025-01-30
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-02-12
D · Potential for more than minimal harm
2025-01-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-12
D · Potential for more than minimal harm
2025-01-30
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-02-12
D · Potential for more than minimal harm
2025-01-30
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-02-12
D · Potential for more than minimal harm
2025-01-30
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-02-12
D · Potential for more than minimal harm
2025-01-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-12
D · Potential for more than minimal harm
2025-01-17
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-01-22
D · Potential for more than minimal harm
2024-11-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-12-02
D · Potential for more than minimal harm
2024-11-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-25
F · Potential for more than minimal harm
2023-12-06
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-12-20
F · Potential for more than minimal harm
2023-12-06
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-12-20
E · Potential for more than minimal harm
2023-12-06
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2023-12-20
E · Potential for more than minimal harm
2023-12-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-20
D · Potential for more than minimal harm
2023-12-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-20
D · Potential for more than minimal harm
2023-12-06
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-12-20
D · Potential for more than minimal harm
2023-12-06
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-12-20
D · Potential for more than minimal harm
2023-10-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-06
E · Potential for more than minimal harm
2023-08-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-21
F · Potential for more than minimal harm
2022-11-04
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-11-30
F · Potential for more than minimal harm
2022-11-04
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2022-11-30
Penalties and ownership
What sits behind the stars
Ownership
Flagstone Healthcare Central LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Keetch, Chad
Corporate Officer · Individual
Little, Gary
Operational/Managerial Control · Individual
Matar, Mousa
Operational/Managerial Control · Individual
Willits, Adam
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Riverside Behavioral Healthcare Center
Riverside, CA
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
Community Care On Palm
Riverside, CA
3-star overall rating with 2-star inspections with $33,540 in total fines with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Community Care And Rehabilitation Center
Riverside, CA
3-star overall rating with 2-star inspections with 23 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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