Health inspection·February 21, 2025

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 notify the primary care physician (PCP), when one of five sampled residents (Resident 2), refused to receive wound care. Residents Affected - Few This failure placed Resident 2 ' s wounds at risk for delayed healing and had the potential for complications such as severe infection, hospitalization, and death, because of the refusal. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated, Resident 2 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 2 ' s diagnoses included encounter for orthopedic (a branch of medicine that focuses on injuries and diseases of the musculoskeletal system) aftercare following surgical amputation (a surgical procedure to remove a limb or other body part). During a review of Resident 2 ' s Minimum Data Set ([MDS], a federally mandated resident assessment tool) dated, 12/12/2024, the MDS indicated Resident 2 was cognitively intact (having the ability to think, remember, and solve problems). The MDS indicated Resident 2 was dependent (helper does all the effort) for Activities of Daily Living (ADLs) such as toileting hygiene and required substantial/maximal assistance (helper does more than half the effort) to perform ADLs of lower body dressing and putting on/off footwear. During a review of Resident 2 ' s Treatment Administration Record (TAR) for January 2025, the TAR indicated the following treatment administration orders: a. Left Below Knee Amputation (BKA) surgical: cleanse with normal saline (NS), pat dry, paint with betadine solution, and cover with dry dressing then wrap with kerlix every day and as needed if soiled/dislodged for 21 days, start date on 1/4/2025. b. Left BKA: cleanse with normal saline (NS), pat dry, paint with betadine solution, and cover with dry dressing then wrap with kerlix (a type of bandage) every day and as needed if soiled/dislodged for 21 days, started on 1/26/2025. c. Right lower leg: cleanse with normal saline, pat dry paint with betadine solution, leave open to air every day shift for diffuse scabs for 21 days, started on 1/26/2025. d. Abdomen multiple scattered, discolorations: monitor for skin integrity every day every shift for 21 days, started on 1/1/2025. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 055045 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 02/21/2025 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)