Health inspection·February 29, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On February 29, 2024, at 1:35 p.m., the MD was observed going into room [ROOM NUMBER] to measure the temperature of the bathroom hot water. The bathroom hot water was observed turned on and measured at 76.1 degrees. The hot water was left running for five minutes and re-measured by the MD. At 1:40 p.m., the MD re-measured the hot water at 100.7 degrees. On February 29, 2024, at 1:41 p.m., the MD was observed going into room [ROOM NUMBER] to measure the bathroom hot water temperature. The bathroom hot water was observed turned on and measured at 87.8 degrees. The hot water was left running for five minutes and re-measured by the MD. At 1:45 p.m., the MD re-measured the hot water at 107 degrees. The MD stated the rooms hot water was getting warmer faster due to the water running for the past 15 minutes while measuring the water temperature in the previous rooms. On February 29, 2024, at 1:45 p.m., the MD was observed going into room [ROOM NUMBER] to measure the bathroom hot water temperature. The bathroom hot water was observed turned on and measured at 73.4 degrees. The hot water was left running for five minutes and re-measured by the MD. At 1:48 p.m., the MD re-measured the hot water temperature at 113 degrees. While measuring the water temperature in room [ROOM NUMBER], Resident 5 was observed dressed lying on the bed. During a concurrent interview, Resident 5 stated the bathroom did not have hot water for months. Resident 5 stated she only used the bathroom to wash her hands because it was too cold to wash anything else. Resident 5 stated sometimes she let the water run for up to an hour and it still did not get warm. On February 29, 2024, at 1:49 p.m., a follow-up interview was conducted with the MD. The MD stated the residents should have hot water available for use. The MD stated the residents should not have to run the water for long periods of time just to get hot water. The MD stated the water should be warm/hot within five minutes of turning on. On February 29, 2024, at 1:55 p.m., an interview was conducted with the Administrator (Adm). The Adm stated the facility water temperature should be between 105-120 degrees for resident comfort. The Adm stated it was reasonable to have the water warm within five minutes of turning the hot water on. The Adm stated the residents should not have to wait longer than five minutes to have access to warm water. On February 29, 2024, Resident 5's record was reviewed. Resident 5 was admitted to the facility on [DATE], and re-admitted [DATE], with diagnoses which included end stage renal disease (ESRD-kidneys cease to function properly requiring mechanical assistance from dialysis), diabetes mellitus (abnormal sugar in the blood), and legal blindness. Review of Resident 5's Physician History and Physical indicated Resident 5 had capacity to understand and make decisions. On February 29, 2024, at 2:38 p.m., an interview was conducted with the Treatment Nurse (TxN). The TxN stated residents should have hot water available for use. The TxN stated she used the resident bathrooms to wash her hands before and after wound care and it was important to have hot water available. On February 29, 2024, at 3:18 p.m., an interview was conducted with CNA 1. CNA 1 stated sometimes it took up to 15 minutes to get warm water in the resident bathrooms. CNA 1 stated some residents complained that care was delayed while they waited for the water to warm up. CNA 1 stated they used to resident ' s bathroom to get warm water to provide peri-care after brief (adult diapers) changes. On February 29, 2024, at 3:21 p.m., an interview was conducted with CNA 2. CNA 2 stated it took up (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055409 If continuation sheet Page 2 of 7 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 055409 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care and Rehabilitation Center 4070 Jurupa Avenue Riverside, CA 92506 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 0584 Level of Harm - Minimal harm or potential for actual harm to 15 minutes or longer to get warm water in some of the resident rooms. CNA 2 stated when a resident needed a brief changed, she would turn on the hot water, assist another resident and then return 10-15 minutes later to provide care. CNA 2 stated some residents did complain about not having warm water to provide care immediately. CNA 2 stated the residents should not have to wait to receive care just because the water was not warm timely. Residents Affected - Some On February 29, 2024, at 4:10 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated residents should not have to wait 15-20 minutes to have access to warm/hot water. The DON stated residents should have warm/hot water available to them. Review of the facility document titled, Safe Water Temperatures, revised January 19, 2022, indicated, .It is the policy of this facility to maintain appropriate water temperatures in resident care areas .Staff will report abnormal findings, such as complaints of water too cold .to the supervisor and/or maintenance staff . Review of the facility document titled, Safe and Homelike Environment, revised December 19, 2022, indicated, .In accordance with residents ' rights, the facility will provide a safe, clean, comfortable and homelike environment .Environment refers to any environment in the facility .including .the residents ' rooms, bathrooms . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055409 If continuation sheet Page 3 of 7 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 055409 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care and Rehabilitation Center 4070 Jurupa Avenue Riverside, CA 92506 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, for one of five residents reviewed (Resident 1), professional standards of practice were followed when the physician ' s order for follow up appointment was not carried out on January 26, 2024. Residents Affected - Few This failure had the potential for care and services for Resident 1 to be delayed. Findings: On February 20, 2024, the department received a complaint indicating Resident 1 had a follow up appointment with her spinal surgeon. The complainant indicated the day of Resident 1 ' s scheduled appointment she received notice that Resident 1 could not attend her appointment due to issues with transportation. On February 29, 2024, at 10:30 a.m., an unannounced visit was conducted at the facility for two complaints. On February 29, 2024, Resident 1 ' s record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included fracture of the first cervical vertebrae (bones in the neck/spine), fracture of the thoracic vertebrae (bones in the chest area of the spine), and history of falls. Review of Resident 1 ' s Physician Order Summary indicated, .F/U (follow up) appt (appointment) on 1/26/24 with spine surgeon . Review of Resident 1 ' s nursing progress notes dated January 26, 2024, indicated there was no documentation regarding Resident 1 ' s scheduled follow up appointment with the spinal surgeon. There was no documented evidence Resident 1 attended her appointment as ordered. There was no documentation transportation had been arranged for Resident 1 to attend her appointment. On February 29, 2024, at 3:25 p.m., an interview was conducted with the Social Service Director (SSD). The SSD stated when outside appointments were scheduled social service would assist with transportation as needed. The SSD stated the Case Manager (CM) would contact social services to arrange transportation and the request was placed on the calendar. During a concurrent record review, the SSD stated Resident 1 had an appointment for January 26, 2024, to follow up with the spinal surgeon. The SSD stated there was no documentation Resident 1 attended the appointment. The SSD stated there was no documentation on the calendar a ride was arranged for Resident 1 to attend the appointment. The SSD stated Resident 1 should have gone to the follow up appointment as scheduled, and transportation arranged. On February 29, 2024, at 3:45 p.m., an interview was conducted with the CM. The CM stated after nursing input an order for appointments, case management would work with the resident and/or families to assist with authorization and transportation. During a concurrent record review, the CM stated Resident 1 had a scheduled follow up appointment scheduled for January 26, 2024, with the spinal surgeon. The CM stated she had received authorization for the appointment on January 17, 2024, but had no other documentation regarding Resident 1 ' s appointment. The CM stated there was no documentation that indicated Resident 1 attended the physician ordered appointment. The CM stated there was no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055409 If continuation sheet Page 4 of 7 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 055409 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care and Rehabilitation Center 4070 Jurupa Avenue Riverside, CA 92506 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few documentation transportation was arranged for Resident 1. The CM stated Resident 1 should have had transportation arranged and gone to her appointment as ordered. On February 29, 2024, at 4:10 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated residents should go to scheduled appointments as ordered and the facility was responsible for helping with transportation as needed. The DON stated staff should chart when the resident left the facility and returned with any new orders received. The DON stated when a resident missed their appointment there should be documentation indicating why and any new appointments scheduled. The DON stated Resident 1 should have gone to the scheduled appointment as ordered and there was no documentation to indicate she did. Review of the facility document titled, Transportation revised January 22, 2024, indicated, .Our facility shall help arrange transportation for residents as needed .Social services will help the resident as needed to obtain transportation . Review of the facility document titled, Provision of Physician Ordered Services revised May 15, 2023, indicated, .The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality .Professional Standards of Quality means that care and services are provided according to accepted standards of clinical practice. Standards may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting .the Physician has requested that the services be performed at an off-site facility, this facility will work with the resident and their family to secure appropriate transportation arrangements for such appointments .Follow-up appointments: Facility staff will assist residents in scheduling and attending follow-up appointments as ordered by the physician .Necessary documentation of scheduled appointments and resident attendance may be maintained . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055409 If continuation sheet Page 5 of 7 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 055409 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care and Rehabilitation Center 4070 Jurupa Avenue Riverside, CA 92506 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 implement interventions which had the potential to result in, and/or contribute to, the worsening of a pressure injury/ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for one of five residents (Resident 1), when Resident 1 was admitted to the facility with a pressure ulcer/injury on the coccyx (base of the spine) and there were no documented skin assessments after admission. Residents Affected - Few This failure had the potential to place the resident at an increased risk for pain and infection. Findings: On February 29, 2024, at 10:30 a.m., an unannounced visit was conducted at the facility for two complaints. On February 29, 2024, Resident 1 ' s record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included fracture of the first cervical vertebrae (bones in the neck/spine), fracture of the thoracic vertebrae (bones in the chest area of the spine), and history of falls. Review of Resident 1 ' s COMS-Skin Only Evaluation dated January 15, 2024, at 2:35 p.m., indicated, .Skin Issue #1 Pressure Ulcer/Injury .Location .Coccyx Unstageable (unable to fully determine the extent of the injury due to obscured vision of the base due to slough [dead cells and substances] and/or eschar [dried blood and tissue]) .Length (cm[centimeters]) .4.1 .Width (cm) .3.5 .Depth (cm) .UTD (unstageable) .Wound bed .Slough . The only other nursing skin assessment for Resident 1 was dated February 2, 2024, at 4:06 p.m., the document was blank and did not have any entries. Review of Resident 1 ' s care plan dated January 25, 2024, indicated, .Focus .The resident had Unstageable PI (pressure injury) to coccyx .Goal .The resident ' s will (sic) Pressure ulcer will show signs of healing .Interventions .Assess/record/monitor wound healing on a weekly basis and as needed. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to MD and resident/resident representative . Review of the facility document titled Surgical Consult dated February 1, 2024, (17 days after Resident 1 was admitted ) indicated, .Reason for visit .to manage a wound located on the sacrococcyx .wound area was 7 cm x 8 cm x Utd . Review of Resident 1 ' s nursing progress note dated February 9, 2024, at 10:10 a.m., indicated, .Resident d/c (discharged ) . There was no documented skin assessment. On February 29, 2024, at 2:38 p.m., an interview was conducted with the Treatment Nurse (TxN). The TxN stated a complete skin assessment was conducted on admission and discharge. The TxN stated when a pressure ulcer/injury was identified the wound was measured and assessed. The TxN stated the wound care physician would be notified for weekly treatments. The TxN stated the resident was then placed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055409 If continuation sheet Page 6 of 7 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 055409 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care and Rehabilitation Center 4070 Jurupa Avenue Riverside, CA 92506 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on daily wound care with weekly skin assessments to include measurements. The TxN stated when a resident admitted with wounds it was important to document the measurements to see if interventions and wound care were working. The TxN stated residents with pressure ulcers/injuries were also assessed upon discharge for follow-up wound care with home health. During a concurrent record review, the TxN stated Resident 1 admitted on [DATE] with a pressure ulcer/injury. The TxN stated Resident 1 received daily wound care but there was no documented weekly skin assessment to determine if the wound care was effective. The TxN stated the wound care physician was not notified until February 1, 2024, almost three weeks after Resident 1 ' s admission. The TxN stated when the wound care physician assessed Resident 1 ' s wound the wound had gotten worse. The TxN stated there was no way to determine when Resident 1 ' s pressure ulcer/injury deteriorated. The TxN stated Resident 1 should have had the wound care physician consulted sooner and had documented weekly skin assessments and she did not. The TxN stated Resident 1 ' s pressure ulcer/injury should have been assessed upon discharge and it was not. On February 29, 2024, at 3:10 p.m., an interview was conducted with the Wound Care Physician (WCP). The WCP stated he was at the facility every Thursday evaluating and doing wound care for residents. The WCP stated the first wound care assessment and treatment for Resident 1 was on February 1, 2024. The WCP stated Resident 1 ' s wound was terminal, but he should have been notified when she was admitted for assessment and weekly treatment evaluations. On February 29, 2024, at 4:10 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated residents should have weekly skin assessments done and documented when they were identified with pressure ulcers/injuries on admission. The DON stated Resident 1 was admitted with a pressure ulcer/injury and the wound care physician should have been contacted sooner for treatment. The DON stated Resident 1 should have had weekly skin assessments done to determine if wound care and treatment were effective, and she did not. Review of the facility document titled, Skin Assessment revised December 19, 2022, indicated, .It is our policy to perform a full body skin assessment as part of our systemic approach to pressure injury prevention and management .A full body, or head to toe assessment will be conducted .upon admission/re-admission, and weekly thereafter .Document of skin assessment .include date and time .Document observations .type of wound .Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain) . Review of the facility document titled, Pressure Injury Prevention and Management revised September 12, 2023, indicated, .This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries .establish and utilize a systemic approach for pressure injury prevention and management, including prompt assessment and treatment .monitoring the impact of interventions; and modifying the interventions as appropriate .Licensed nurses will conduct a full body skin assessment at least weekly after admission .findings will be documented in the medical record .Monitoring .The progression towards healing, or lack of healing, of any pressure injuries weekly as needed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055409 If continuation sheet Page 7 of 7