Health inspection·April 10, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm A review of Resident 1's care plan titled, At risk for injuries related to impaired bed mobility, dated 1/12/2019, indicated intervention to provide resident a safe environment. A review of Resident 1's Physical Therapy evaluation dated 1/26/2024, indicated Resident 1's bed mobility was total dependence without attempts to initiate. Residents Affected - Few A review of Resident 1's Occupational Therapy Evaluation, dated 1/26/2024, indicated Resident 1 was unable to sit or stand during activities of daily living. The evaluation indicated Resident 1 was totally dependent without attempts to initiate on all activities of daily living. A review of Resident 1's Change in Condition Evaluation (COC), dated 3/16/2024, indicated on 3/16/2024 while a Certified Nurse Assistant (CNA1) was cleaning Resident 1 by herself, Resident 1 was on a low air loss mattress (a device which is used to help prevent nursing home residents from getting bed sores) for skin management. The COC indicated CNA 1 turned Resident 1. Resident 1 sled near the edge of the bed. The COC indicated, CNA1 assisted Resident 1 back to the center of the bed to regain her balance. The COC indicated Resident 1 had a pain level of 3 (0 is no pain, 1-3 mild pain, 4-6 moderate pain, 7-10 severe pain) in her body due to the movement after repositioning. The COC indicated Resident 1 was given pain medication for general body pain. A review of Resident 1's radiology (process of taking pictures to diagnose and treat diseases) report dated 3/17/2024, indicated acute left proximal tibia and fibula (long bone in the lower leg) fracture (broken bone). A review of Resident 1's COC, dated 3/17/2024, indicated on 3/17/2024, the left lower extremity was warm to touch. The COC indicated x-ray (a test used to generate images of tissues and structures inside the body) result for Resident 1 was left proximal tibia and fibula fracture. The COC indicated the intervention for the fracture was to immobilize the left lower extremity and transfer to the GACH. A review of Resident 1's undated Rehab to Nursing Communication indicated Resident 1 required two persons assist for bed mobility, transferring, and toileting. A review of Resident 1's GACH Emergency physician notes dated 3/17/2024, indicated Resident 1 fell out of bed on 3/16/2024, at a skilled nursing facility (SNF), and complained of a left lower leg pain. The report indicated Resident 1's x-ray from the SNF indicated the resident had a closed comminuted left tibia and fibula fracture and was transferred to the GACH for further evaluation. The note indicated a facility's staff reported that Resident 1 was caught before she fell. The note indicated the distress of the fall prevention may have caused a pathological fracture (a broken bone in an area that was already weakened by another disease).The report indicated Resident 1 complained of pain to the left lower leg when palpated (touched) or with movement. During an interview with Resident 1 on 4/2/2024 at 12:27 p.m., Resident 1 stated she was transferred to a GACH after she fell and hit the ground, while at the facility. Resident 1 stated she was crying a lot because after the fall, her left leg hurt so bad. During an interview with CNA 1 on 4/2/2024 at 1:13 p.m., CNA 1 stated she was caring for Resident 1 with Licensed Vocational Nurse (LVN 1) and as CNA 1 turned Resident 1 towards her, Resident 1 was at the edge of the bed and Resident 1 got scared she was going to fall. CNA 1 stated she (CNA 1) caught Resident 1, and LVN 1 and CNA 1 recentered Resident 1 back to the center of the bed. CNA 1 stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055045 If continuation sheet Page 2 of 4 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 055045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riviera Healthcare Center 8203 Telegraph Rd Pico Rivera, CA 90660 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 0689 Resident 1 did not fall off the bed. CNA 1 stated Resident 1 used a low air loss mattress. Level of Harm - Minimal harm or potential for actual harm During a phone interview with Licensed Vocational Nurse (LVN 1) on 4/2/2024 at 3:11 p.m., LVN 1 stated she was walking towards the nurses' station near Resident 1's room when she (LVN 1) heard Resident 1 yelling. LVN 1 stated she went into the room and saw Resident 1 at the edge of the bed. LVN 1 stated CNA 1 was trying to reposition resident back to the center of the bed by herself. LVN 1 stated she assisted CNA 1 to reposition Resident 1 back to the center of the bed. LVN 1 stated Resident 1 complained of pain because of sudden movement. LVN 1 stated, CNA 1 probably turned Resident 1 too quickly. Residents Affected - Few During an interview with Certified Occupational Therapist Assistant (COTA 1), on 4/9/2024 at 1:12 p.m., COTA 1 stated Resident 1 was totally dependent on staff for all activities of daily living. COTA 1 stated total dependence required a two person assist for safety and body mechanics. COTA 1 stated Resident 1 required two people for turning safely because Resident 1 did not have the strength to hold the side-lying position. During an interview with the Assistant Director of Nursing (ADON) on 4/9/2024 at 3:21 p.m., the ADON stated Resident 1 was on low air loss mattress. The ADON stated a CNA must change the low air loss mattress setting to firm when performing resident care, otherwise the resident could slide off the bed. The ADON stated if there was only one CNA performing care and the CNA did not change the setting, the resident could slide out during care. During an interview with the Director of Staff Development (DSD) on 4/10/2024 at 10:23 a.m., the DSD stated staff always have to change the low air loss mattress settings no matter if there was one person or two persons providing care. The DSD stated if the low air loss mattress setting were not changed, it placed the staff and residents at risk for injury. The DSD stated Resident 1 required two persons assist for bed mobility per the rehab to nursing communication, located in Resident 1's room. The DSD stated the rehab to nursing communication was in each resident's room and provided information for staff regarding each resident's mobility status. During an interview with CNA 1 on 4/10/2024 at 10:49 a.m., CNA 1 stated she did not adjust Resident 1's low air loss mattress settings prior to providing Resident 1 care. During a concurrent interview and record review with the Director of Nursing (DON) on 4/10/2024 at 11:39 a.m., Resident 1's care plan titled, At risk for spontaneous pathological fracture related to osteopenia was reviewed. The DON stated the intervention to prevent pathological fractures was to handle resident gently during care. The DON stated handling gently required turning the resident carefully. The DON stated Resident 1 used a low air loss mattress and staff (CNA) must check the settings and make sure it was correct. The DON stated CNAs were not allowed to change settings because they might forget to change it back. During an interview with the DSD on 4/12/2024 at 12:44 p.m., the DSD stated the treatment nurse, charge nurse, and CNA can change the settings on the low air loss mattress while providing care to the resident. During a review of the undated operator's manual for the Med Air Plus 8 Alternating Pressure and Low Air Loss Mattress Replacement System, the manual indicated, an even surface will make the transfer or reposition of the patient easier and static mode will provide an even support surface for the patient. The manual indicated, for nursing and caring convenience, to press the auto firm button to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055045 If continuation sheet Page 3 of 4 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 055045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riviera Healthcare Center 8203 Telegraph Rd Pico Rivera, CA 90660 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete automatically inflate the mattress to the maximum level for about 30 minutes and after 30 minutes, the control unit will return to the previously set weight setting and pressure level. During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, dated 1/2024, the P&P indicated resident safety and assistance to prevent accidents are facility-wide priorities. The P&P indicated; the care team shall target interventions to reduce individual risks related to hazards in the environment and interventions to reduce accident risks and hazards, should include communicating specific interventions to all relevant staff, providing training as necessary, and ensuring that interventions are implemented. Event ID: Facility ID: 055045 If continuation sheet Page 4 of 4