Inspection·August 7, 2025

F 0657 Level of Harm - Minimal harm or potential for actual harm policy and procedure titled Person-Centered Care Plan, dated May 22, 2025, indicated .Comprehensive care plans must be reviewed and revised by the interdisciplinary team after each assessment.A review of the facility policy and procedure titled Skin Integrity Management, dated July 31, 2024, indicated .Interdisciplinary Team (IDT) /Skin Committee will document discussion and recommendations for skin integrity issues .Review the resident's care plan and update as necessary . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055042 If continuation sheet Page 2 of 13 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 055042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alta Vista Healthcare & Wellness Centre 9020 Garfield Street 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure services provided meet professional standards of practice for one of five residents reviewed (Resident 4) when the facility did not clarify the physician's order for behavior monitoring during the use of an antipsychotic medication (drugs that affect brain chemicals to stabilize mood and thoughts), Vraylar (an antipsychotic medication used to treat bipolar disorder and schizophrenia). These failures had the potential for Resident 4 to receive Vraylar without adequate target behavior monitoring to assess the effectiveness of the medication. A review of Resident 4's admission Record, dated August 7, 2025, indicated Resident 4 was admitted on [DATE], with diagnosis of bipolar disorder (a mental health condition that causes extreme shifts in mood, energy, and activity levels). A review of the Physicians Orders indicated the following antipsychotic medication and behavior monitoring orders for Resident 4:- On May 13, 2025, Vraylor capsule 1.5 mg (milligrams, unit of measurement) one capsule by mouth one time a day for Bipolar Disorder as m/b (manifested by) episodes of manic behavior; and- On May 21, 2025, Monitor target behaviors for use of Vraylar due to Bipolar Disorder insert behaviors manifested/target behaviors. A review of Resident 4's medication administration record (MAR) dated May 28, 2025 through August 7, 2025, indicated nursing staff administered Resident 4 one Vraylar tablet daily and documented monitoring of target behavior for use of Vraylar as insert behaviors manifested/target behaviors without clarification of the specific target behavior on the following days: - On May 28, 2025, to May 31, 2025;- On June 1, 2025, to June 7, 2025;- On June 10, 2025, to June 30, 2025, and - On July 21, 2025, to August 7, 2025. During a concurrent interview and record review on August 7, 2025, at 8:12 a.m. with the Director of Nursing (DON), Resident 4's clinical record, including the provider orders as listed above and MARs dated May 28, 2025 through August 7, 2025, were reviewed. The DON acknowledged the order on May 21, 2025 for monitoring of target behaviors during use of Vraylar due to bipolar disorder insert behaviors manifested/target behaviors was unclear and stated nursing staff were expected to have clarified the missing target behavior on May 21, 2025 when the order was received by nursing staff for Resident 4.A review of the facility's policy and procedure (P&P) titled, Preparation and General Guidelines, revised February 2020, indicated, Medications are administered as prescribed in accordance with good nursing principles and practices.Medications are administered in accordance with written orders of the prescriber.If.a medication order seems to be unrelated to the resident's current diagnosis or conditions, the nurse calls the provider pharmacy for clarification prior to the administration of the medication or if necessary contacts the prescriber for clarification. This interaction with the pharmacy and/or prescriber and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055042 If continuation sheet Page 3 of 13 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 055042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alta Vista Healthcare & Wellness Centre 9020 Garfield Street 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide the necessary care and services to maintain intravenous (the administration of fluids, medications directly into a vein) access for two of eight residents (Resident 6 and 68) when: 1.Resident 6's PICC line (peripherally inserted central catheter) dressing was changed in a timely manner.2.Resident 68's peripheral dressing (a transparent covering placed over a peripheral intravenous insertion site) was labeled with the date, time and nurse's initials. These failures had the potential to delay the identification of intravenous catheter-related complications and result in infection, placing the residents at risk for worsened health conditions. Findings:1. On August 4, 2025, at 9:45 a.m., Resident 6 was observed sitting up in bed with a PICC line on the left forearm with a transparent dressing dated July 23, 2025. Resident 6 stated he had been receiving IV antibiotic medications for five weeks. A review of the admission record indicated Resident 6 was admitted to the facility on [DATE], with diagnoses that included endocarditis (an infection of the heart's inner lining, usually involving the heart valves. A review of Resident 6's physician's order dated July 4, 2025, indicated, .change dressing and cap every day shift every 7 days.A review of Resident 6's care plan, dated July 4, 2025, indicated, .the resident is on IV medication r/t endocarditis .the resident will not have any complications related to IV therapy .On August 4, 2025, at 9:50 a.m., a concurrent observation and interview was conducted with Registered Nurse Supervisor (RNS). RNS stated, Resident 6's dressing should have been changed on July 30, 2025. On August 6, 2025, at 11:23 a.m., an interview was conducted with the Infection Preventionist (IP), the IP stated the PICC line dressing should be changed every seven days to prevent irritation and possible infection on the IV (intravenous) site.On August 7, 2025, at 12:20 p.m., an interview was conducted with the Director of Nursing (DON), the DON stated Resident 6 has an order for dressing to be changed every seven days, and it should have been changed on the 30th of July. The DON stated, if the licensed nurse identified that the date was out of range, the expectation would be to change the dressing immediately to ensure the site is clean and free from infection, which could affect the resident.A review of the facility's policy and procedure titled Central Venous Catheter Dressing Changes dated, July 2013, indicated, .change transparent semi-permeable membrane dressings every 5 to 7 days and PRN (when wet, soiled, or not intact) .2. On August 4, 2025, at 10:20 a.m., Resident 68 was observed in bed with a peripheral line dressing noted on the left hand, which was not labeled with the date, time, and initials. A review of the admission record indicated Resident 68 was admitted to the facility on [DATE], with diagnoses that included bacteremia (bacteria is present in the bloodstream). A review of Resident 68's physician's order dated July 21, 2025, indicated, .change peripheral IV line and dressing every 48 hours.A review of Resident 68's care plan report, dated July 20, 2025, indicated, .the resident is on antibiotic therapy .the resident will be free from any discomfort or adverse side effects of antibiotic therapy .On August 4, 2025, at 10:28 a.m., a concurrent observation and interview was conducted with the IP, the IP stated, Resident 68's dressing should have been labeled with the date, time, and initials in order to prevent infection.On August 7, 2025, at 12:20 p.m., an interview was conducted with the DON, the DON stated Resident 68 had an order to check the site every shift and change the dressing every 48 hours. The DON further stated, it was the facility's policy to label all IV dressings with date, time, and initials, to prevent infection.A review of the facility's policy and procedure titled Peripheral IV Dressing Changes dated, July 2013, indicated, .Peripheral IV dressing will be changed when needed to prevent catheter related infections associated with contaminated, loosened or soiled catheter-site dressing.apply and maintain transparent semi-permeable Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055042 If continuation sheet Page 4 of 13 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 055042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alta Vista Healthcare & Wellness Centre 9020 Garfield Street 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 0694 membrane dressing or sterile gauze for all peripheral intravenous catheter sites.label dressing with date, time and initials. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055042 If continuation sheet Page 5 of 13 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 055042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alta Vista Healthcare & Wellness Centre 9020 Garfield Street 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure for one of one sampled resident reviewed for respiratory care (Resident 9) the licensed staff document before and after nebulizer assessments as ordered by the physician and evaluate the effectiveness of treatment. This failure had the potential to cause Resident 9 not to receive effective treatment and relief during episodes of respiratory distress. Findings:On August 4, 2025, at 11:11 a.m., a concurrent observation and interview was conducted with Resident 9. Resident 9 was observed coughing and stated she had shortness of breath. Resident 9 stated she had to asked for her breathing treatment and nobody checked her to see if it helped. A review of Resident 9's admission Record indicated Resident 9 was admitted to the facility on [DATE], with diagnoses which included COPD (a group of lung diseases that block airflow and make it difficult to breathe) and asthma (chronic respiratory condition characterized by inflamed and narrowed airways, making it difficult to breathe).A review of Resident 9's History and Physical, dated July 15, 2025, indicated Resident 9 had the capacity to understand and make decisions.A review of Resident 9's Order Summary Report, for the month of August 2025, indicated:- Dated July 14, 2025, Ipratropium-Albuterol. inhalation solution, 3 ml (milliliter-unit of measurement) inhale orally via nebulizer (breathing machine) every 4 hours as needed [PRN] for SOB (shortness of breath).-Dated July 14, 2025, After nebulizer treatment-document Pulse, RR [respiratory rate], O2 sat [saturation] (RA or L/min), LS (lung sound).-Dated July 14, 2025, Before nebulizer treatment- document .RR (respiratory rate), O2 sat (oxygen saturation) (RA (room air) or L/min (liter/minute- unit of measurement), LS each side.(NC- Normal Clear, W- wheezing (a high-pitched whistling sound produced when air flows through narrowed airways in the lungs), R- Rhonchi (continuous, low-pitched, rattling lung sounds that are often described as resembling snoring or gurgling), C- Crackles ( abnormal, discontinuous, nonmusical breath sounds heard during auscultation (listening) of the lungs) .A review of Resident 9's Medication Administration Record (MAR) for the month of July 2025 and August 2025, indicated Resident 9 was administered with 21 PRN nebulizer treatments on the following dates:-July 1, 2, 4, 6, 8, 9, 10, 15, 16, 19, 22, 25, 27, 28, 2025; and-August 4, 2025.Further review of Resident 9's MAR indicated there was no documentation of before and after treatment respiratory assessments or post treatment evaluations of effectiveness as ordered. On August 7, 2025, at 4:08 p.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated the respiratory therapy documentation was not being completed for July and August 2025. The DON stated, the physician order requires before and after assessments, and the documentation should reflect both administration and effectiveness. The DON stated, the licensed nurses should have assessed Resident 9 before and after treatment and the assessments should have been documented. A review of the facility policy and procedure titled, Nebulizer, dated October 15, 2020, indicated .Monitor breath sounds, oxygen saturation, and pulse before and after treatment.Obtain the Resident's pulse during the treatment.Record all pertinent information in respiratory therapy notes and/or on the Medication Administration Record (MAR). Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055042 If continuation sheet Page 6 of 13 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 055042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alta Vista Healthcare & Wellness Centre 9020 Garfield Street 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure pain assessment and management were performed, for two of four residents reviewed (Resident's 12 and 7). This failure had the potential for Resident's 12 and 7 to experience pain and discomfort which could negatively impact mental and physical well-being. Findings: Residents Affected - Few 1a. On August 5, 2025, at 10:30 a.m., an interview was conducted with Resident 12. Resident 12 was alert, resting in bed, and reported that her pain medication was not as effective as she hoped. Resident 12 stated, she recently had surgery and was receiving pain management interventions with medication and positional changes. On August 6, 2025, A review of Resident 12's record was conducted. Resident 12 was admitted [DATE], with diagnosis which included, displaced intertrochanteric fracture of right femur (broken portion of the right leg bone). The History and Physical (H&P), dated December 27, 2024, indicated Resident 12 had the capacity to understand and make decisions. A review of the Vitals and Pain only Evaluation dated December 10, 2024, indicated.Pain.should a pain assessment be conducted.Yes. Further review of Resident 12's record indicated there was no pain assessment/evaluation conducted for Resident 12 from January 2025 to July 2025. A review of Resident 12's Progress Notes, dated July 23, 2025, to August 6, 2025, indicated Resident 12 had surgery to the right hip on July 23, 2025. A review of the Physicians Orders indicated the following pain medications: .Dilaudid Oral Tablet 2 MG (milligrams - unit of measurement).Give 1.5 tablet by mouth every 4 hours as needed for Breakthrough Pain 10 NTE (not to exceed) 3 GM (grams – unit of measurement)/24 hours.order date July 22, 2025.active. .Dilaudid Oral Tablet 4 MG.Give 1 tablet by mouth every 6 hours as needed for MODERATE pain (5-7) notify MD if ineffective.order date July 28, 2025.active. .tramadol.Oral Tablet 50 MG.Give 1 tablet by mouth every 4 hours as needed for MILD pain (1-4) Notify MD if ineffective.order date July 28, 2025.active. A review of the Medication Administration Review (MAR) from July to August 2025, indicated the following: July 24, 2025, at 12:00 p.m. - Pain level 8, Dilaudid 2 mg given July 24, 2025, at 6:20 p.m. - Pain level 7, Dilaudid 2 mg given July 25, 2025, at 6:00 a.m. - Pain level 8, Dilaudid 2 mg given (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055042 If continuation sheet Page 7 of 13 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 055042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alta Vista Healthcare & Wellness Centre 9020 Garfield Street 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 0697 July 26, 2025, at 9:23 a.m. - Pain level 6, Dilaudid 2 mg given Level of Harm - Minimal harm or potential for actual harm July 26, 2025, at 6:06 p.m. - Pain level 6, Dilaudid 2 mg given July 27, 2025, at 9:41 a.m. - Pain level 6, Dilaudid 2 mg given Residents Affected - Few July 28, 2025, at 9:25 a.m. - Pain level 8, Dilaudid 2 mg given July 28, 2025, at 6:14 p.m. - Pain level 7, Dilaudid 2 mg given July 31, 2025, at 1:00 p.m. - Pain level 5, Dilaudid 2 mg given August 1, 2025, at 9:24 a.m. - Pain level 8, Dilaudid 2 mg given August 2, 2025, at 9:32 a.m. - Pain level 6, Dilaudid 2 mg given August 3, 2025, at 10:23 a.m. - Pain level 8, Dilaudid 2 mg given August 3, 2025, at 5:31 p.m. - Pain level 8, Dilaudid 2 mg given August 4, 2025, at 10:41 a.m. - Pain level 8, Dilaudid 2 mg given August 4, 2025, at 6:45 p.m. - Pain level 8, Dilaudid 2 mg given August 5, 2025, at 10:51 a.m., - Pain level 8, Dilaudid 2 mg given August 5, 2025, at 6:56 p.m. - Pain level 7, Dilaudid 2 mg given Further review of Resident 12's MAR from July 23, 2025, to August 6, 2025, indicated that the doses did not match the ordered pain scale ranges for Dilaudid 4 mg and 2 mg. A review of Resident 12's Care Plan Osteoporosis initiated November 2, 2022, revised August 1, 2025, indicated, .Give analgesics (medication) PRN (as needed) for pain.Resident may complain of pain.Give medications as ordered.Monitor/document for side effects and effectiveness. On August 6, 2025, at 1:04 p.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN 1). LVN 1 stated, Resident 12 preferred Dilaudid 2 mg and that she honored the resident's request. LVN 1 stated the physician's order was not followed and should have been clarified. LVN 1 further stated there was a potential for ineffective pain management if the medication was not provided according to the physician's order. On August 7, 2025, at 12:49 p.m. an interview was conducted with the Director of Nursing (DON). The DON stated the expectation for pain management was that the LVN should clarify orders that are potentially misleading or do not specify a complete range of coverage for a pain scale. She stated for breakthrough pain medication the nurses should know that pain medication should have a scalable range and if the pain reached a level outside of the range then the breakthrough medication should be provided. A concurrent record review of Resident 12's MAR was conducted with the DON. The DON stated both (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055042 If continuation sheet Page 8 of 13 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 055042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alta Vista Healthcare & Wellness Centre 9020 Garfield Street 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Dilaudid 2 mg and 4 mg were not given to Resident 12 according to the physicians order. The DON stated along with accuracy of administering pain medications the pain management should include a pain assessment and that I should be reviewed at least quarterly. The DON stated there should have been a pain assessment for Resident 12 during the months of March and June of 2025 and there was none. The DON further stated there was a potential for Resident 12 to not receive adequate pain management if the physicians orders were not followed and a pain assessment was not conducted to reflect the residents current pain status. 1b. A review of Resident 7's admission Record, dated August 6, 2025, indicated Resident 7 was initially admitted on [DATE], and re-admitted on [DATE], with diagnoses including osteoarthritis (condition where the protective cartilage in joints breaks down, causing pain) of the knee and acute (sudden) pain due to trauma (injury). A review of Resident 7's History and Physical (H&P), dated June 24, 2025, indicated Resident 7 had the capacity to understand and make decisions. A review of Resident 7's current Minimum Data Set (MDS, a care area assessment and screening tool), dated June 30, 2025, indicated the resident had Brief Interview of Mental Status (BIMS - a tool to assess cognitive function of an individual) score of 14 - (intact cognition). A review of the Care Plan At risk/potential for acute pain/chronic pai related to OA (osteoarthritis) of the knee, initiated June 23, 2025, indicated Administer prescribed pain medication before and after activity and therapy.establish a pain management treatment plan.evaluate pain.monitor for factors/activities that precipitate or aggravate pain. A review of Resident 7's Physicians Orders, dated July 31, 2025, indicated a provider order for Oxycodone-acetaminophen (a potent controlled medication for pain) 10/325 milligram (mg, unit of measurement) every 6 hours as needed for severe pain (7-9). During a medication pass observation on August 6, 2025, at 12:38 p.m. with LVN 3, Resident 7 was observed requesting pain medication and stated having pain level 10 in his neck and back. LVN 3 was observed preparing and administering one oxycodone-acetaminophen 10/325 mg tablet to Resident 7. A review of Resident 7's clinical record on August 6, 2025, at 1:21 p.m., indicated there was no documented evidence of a provider order for pain medication prescribed for pain level 10. During a concurrent interview and record review on August 6, 2025, at 1:51 p.m. with the DON, Resident 7's clinical record, including the provider order for oxycodone-acetaminophen 10/325mg dated July 31, 2025, as listed above, was reviewed. The DON acknowledged the order for oxycodone-acetaminophen 10/325mg was prescribed for severe pain level 7-9 and did not include pain level of 10. The DON stated the expectation was for the nurse to have called and clarified with the provider if pain medication order needed to be changed when Resident 7 reported a pain level outside of the prescribed parameters. A review of the facility policy and procedure (P&P) titled, Pain Management, dated May 2023, indicated, .The Licensed Nurse will administer pain medications as ordered and document medication administered on the Medication Administration Record (MAR).Nursing Staff will provide education to residents.regarding residents pain management program as to appropriate expectations for pain management.A pain assessment will be completed for each resident upon admission, quarterly, when there is a new (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055042 If continuation sheet Page 9 of 13 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 055042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alta Vista Healthcare & Wellness Centre 9020 Garfield Street 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 0697 onset of pain, exacerbation of pain, or when there is a significant change in status. Level of Harm - Minimal harm or potential for actual harm A review of the facility's P&P titled, Preparation and General Guidelines, revised February 2020, indicated, Medications are administered as prescribed in accordance with good nursing principles and practices.Medications are administered in accordance with written orders of the prescriber.If.a medication order seems to be unrelated to the resident's current diagnosis or conditions, the nurse calls the provider pharmacy for clarification prior to the administration of the medication or if necessary contacts the prescriber for clarification. This interaction with the pharmacy and/or prescriber and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055042 If continuation sheet Page 10 of 13 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 055042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alta Vista Healthcare & Wellness Centre 9020 Garfield Street 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure appropriate intervention was provided after a dialysis (the process of removing excess water and cleaning the blood in people whose kidneys no longer work) treatment for one of three residents reviewed for dialysis (Resident 42) when a post dialysis evaluation was not completed on August 7, 2025.This failure to assess and document Resident 42's health status after dialysis had the potential to result in unrecognized complications and delayed interventions. Findings:A review of Resident 42's Dialysis Communication Record, dated August 7, 2025, indicated the post (after) hemodialysis assessment section was left blank and did not contain documentation that Resident 42 was assessed and monitored after returning to the facility. On August 7, 2025, at 2:24 p.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse, LVN 1. LVN 1 stated the post hemodialysis assessment was not completed by the dialysis facility and/or assessed by the assigned nurse.On August 7, 2025, at 3:34 p.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated, post dialysis forms should include a completed assessment and monitoring of the dialysis treatment. The DON further stated any communication from the dialysis clinic must be followed up and documented to show all interventions provided to the resident.A review of the facility's policy and procedures (P&P) titled, Dialysis Management , dated January 25, 2024, indicated, .the Facility will arrange transportation to and from the dialysis provider, as well as for meals, medication administration, and a method of communication between the dialysis provider and the Facility.a pre and post dialysis evaluation will be completed by the licensed nurse.assessing, observing and documenting care of access sites daily, as applicable, such as.dressing will be changed in accordance with attending Physician's order . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055042 If continuation sheet Page 11 of 13 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 055042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alta Vista Healthcare & Wellness Centre 9020 Garfield Street 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications when: 1a. Medication Room in Nursing Station 1 contained one (1) refrigerated medication vial opened without an open date label; and 1b. Medication Cart in Nursing Station 3 contained three (3) medications opened without an open date label.The deficient practices had a potential for residents to receive unsafe and ineffective medications (reduced potency) from being used past their discard (expiration) date and not being removed from active stock.1a. During a concurrent observation and interview on [DATE] at 12:09 p.m. with the Assistant Director of Nursing (ADON), an inspection of the Medication Room in Nursing Station 1 identified one opened refrigerated multi-dose vial (MDV) of Tuberculin PPD (test agent used in the diagnosis of tuberculosis) 5 TU (test unit) per 0.1 ml (milliliter; unit of measurement) did not have an open date label. The ADON stated nursing staff were expected to have labeled the opened PPD vial with an opened date and the PPD vial was good for 30 days when opened according to the manufacturer. The ADON read the manufacturer's instructions printed on the outer box which indicated, Discard opened product after 30 days. When asked why it was important to know when the vial was opened, the ADON stated it was important to track if the vial was opened for more than 30 days to ensure the medication's sterility and potency was maintained. The ADON stated the opened, used and undated PPD vial should have been discarded.A review of the PPD vial manufacturer's instructions dated [DATE], indicated, A vial of [PPD] which has been entered and in use for 30 days should be discarded.1b. During a concurrent observation and interview on [DATE] at 3:21 p.m. with Licensed Vocational Nurse (LVN) 2, an inspection of the Medication Cart in Nursing Station 3 identified the following: - One budesonide inhalation suspension (used to treat asthma symptoms) foil pack with four unused ampules, was opened but did not have an open date;- One prefilled Humulin N KwikPen insulin (used to treat diabetes) pen, was opened but did not have an open date; and- One prefilled Lispro KwikPen insulin pen, was opened but did not have an open date.During the same observation and interview on [DATE] at 3:21 p.m., LVN 2 stated the above medications should have been labeled with open dates. LVN 2 reviewed the manufacturer's instructions on the budesonide inhalation suspension packaging which indicated, Once the foil envelope is opened, use the ampules within 2 weeks . LVN 2 stated the opened budesonide inhalation suspension foil package without an opened date should have been discarded. LVN 2 reviewed the pharmacy's red sticker label on the prefilled Humulin N KwikPen insulin pen which indicated, Discard 14 days after opening. LVN 2 reviewed the pharmacy's red sticker label on the prefilled Lispro KwikPen insulin pen which indicated, Discard 28 days after opening. LVN 2 stated she needed to ask the supervisor regarding what to do with the opened and undated prefilled insulin pens.During an interview on [DATE] at 4:22 p.m. with the ADON, regarding the opened and undated medications as listed above, the ADON stated the expectation was for nursing staff to follow the manufacturer expiration when opened. The ADON stated nursing staff should have written the opened date on the above listed medications. The ADON stated it was important to know the open date to know when the medication would have expired. During an interview on [DATE] at 4:26 p.m., the Director of Nursing (DON) stated the expectation was for nurses to have written the opened date on the medication when they opened it. The DON stated it was important to know the opened date to make sure the medication was still effective, and to ensure stability/sterility of the medication to prevent negative patient outcomes.During a follow-up concurrent interview and record review on [DATE] at 3:06 pm., the DON stated the facility did not have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055042 If continuation sheet Page 12 of 13 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 055042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alta Vista Healthcare & Wellness Centre 9020 Garfield Street 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete a policy regarding medication labeling. The DON stated nurses were expected to follow the manufacturer's instructions and the expirations on a list provided by the pharmacy. The DON provided the document from the pharmacy titled, Appendix 29: Medications with Shortened Expiration Dates, date revised February 2020, it indicated, The following medications have expiration dates shorter than the identified expiration date once placed into use .PPD - Discard 30 days after opened .Insulin - Discard 28 days after opening except for the following Insulins. The following insulins shall be discarded after opening as follows .Humulin N KwikPen (14 days) .Pulmicort (Budesonide) Discard 14 days after opening foil pack . A review of the budesonide inhalation suspension manufacturer's instructions dated [DATE], indicated, When an envelope has been opened, the shelf life of the unused ampules is 2 weeks when protected.A review of the prefilled Humulin N KwikPen insulin pen manufacturer's instructions dated [DATE], indicated, When stored at room temperature, Humulin N KwikPen can only be used for a total of 14 days. A review of the prefilled Lispro KwikPen insulin pen manufacturer's instructions dated [DATE], indicated, When stored at room temperature, Insulin Lispro can only be used for a total of 28 days.A review of the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, revised date February 2020, indicated, Outdated, contaminated, or deteriorated medications.are immediately removed from inventory, disposed of according to procedures for medication disposal.and reordered from the pharmacy. Event ID: Facility ID: 055042 If continuation sheet Page 13 of 13