Health inspection·November 4, 2024

F 0686 A review of Resident 1 ' s Braden Scale for Predicting Pressure Ulcer dated June 21, 2024, indicated she was a high risk for developing PI. Level of Harm - Actual harm Residents Affected - Few On October 22, 2024, at 12:28 p.m., during an interview with Certified Nurse Assistant (CNA) 1, CNA 1 stated the residents' skin condition is monitored every day when their briefs are changed and during showers. CNA 1 stated new skin conditions are reported to the charge nurse. CNA 1 stated Resident 1 was a total care resident, required two-person-assist with most ADLs (activities of daily living), was incontinent, and often refused care. CNA 1 stated Resident 1 had a wound on her buttocks that looked and smelled very bad. CNA 1 stated she was not sure when Resident 1 developed the wound. On October 22. 2024, at 12:58 p.m., during an interview with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the CNAs reported abnormal skin conditions to the licensed or the treatment nurses (TXN) and documented it on the shower sheets. On October 22, 2024, at 1:44 p.m., during an interview with TXN 1, TXN 1 stated residents are assessed for risks of developing skin conditions upon admission. TXN 1 stated the facility conducted skin sweeps where all residents are checked for their current skin condition. TXN 1 stated Resident 1 had a stage 3 PI identified on September 13, 2024. TXN 1 stated it did not make sense to her that Resident 1 ' s PI was at stage 3 when it was identified. TXN 1 stated there were different CNAs assigned to residents for each shift and someone should have noticed something. On October 23, 2024, at 1:09 p.m., during a concurrent interview and record review, the TXN 2 stated the following: a. The facility conducts skin sweep weekly or biweekly depending on staff availability. b. The skin inspection (shower sheet) dated August 10 and August 30, 2024, indicated Resident 1's skin was not intact and skin problem was identified by the CNA on the buttocks area and sacral area, respectively. c. The physician's orders, progress notes, and Treatment Administration Record (TAR), for August 2024, did not have documentation reflecting the skin issues identified on August 10 and August 30, 2024. Also, the TAR did not reflect treatment was initiated. d. A skin sweep was conducted on September 13, 2024, when Resident 1's stage 3 PI on the sacrococcyx extending to the right buttock was discovered. A review of Resident 1's weekly summaries indicated a weekly summary was not completed on August 31, 2024, to reflect the status of the skin issue on the sacral area identified on August 30, 2024, during skin inspection. On October 23, 2024, at 4:16 p.m., during an interview and concurrent record review with the Director of Nursing (DON), the DON stated the CNAs checked residents ' skin when they change them and during showers. The DON stated the CNAs uses shower sheets to document any skin issues and they would verbally communicate with the LVNs. The DON stated when CNAs report skin issues, the charge nurse needs to look at the patient and verify the skin issue. The DON stated if the skin issue was verified, the charge nurse communicates with the TXN so that the TXN can re-evaluate the resident. The DON stated the TXNs conducted a skin sweep for all residents monthly to ensure that no skin issue was missed. The DON stated the TXN conducted weekly skin evaluation, and the charge nurses conducted weekly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055409 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 055409 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2024 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 - Actual harm Residents Affected - Few summary where the residents' skin is assessed as well. The DON verified that Resident 1 did not have a weekly summary for August 24 and 31, 2024. The DON stated the nurses should be conducting their weekly summaries to document a summary of the residents ' condition. On November 4, 2024, at 11:28 a.m., a concurrent interview with CNA 2 and record review of Resident 1 ' s Skin Inspection dated August 30, 2024, was conducted. CNA 2 stated it was her signature on the document and she identified Resident 1 had redness on her right arm and a small open wound on her sacral area. CNA 1 stated she reported her findings to the charge nurse and treatment nurse that same day (August 30, 2024). A review of the Skin Only Evaluation dated September 13, 2024, indicated Resident 1 was noted with a stage 3 (full-thickness loss of skin tissue that appears as a crater-like sore, with dark patches of skin around the edges) pressure injury on her Sacro coccyx (tail bone) extending to the right buttock after conducting a skin sweep (checks the entire body for any skin wounds, as well as wound prevention). The wound measured 5.5. cm (length) x 2.5 cm (width) x 0.2 cm (depth), the wound bed was 80% slough (yellow/white material on the wound bed) and 20% granulation tissue a new connective tissue that forms in a wound during the healing process) with minimal serous drainage (clear fluid that leaks out of wounds), peri (around) wound is erythematous (inflamed skin). A review of Resident 1's physician's order, dated September 14, 2024, indicated, .Wound type: Stage 3 PI Wound site: Sacro coccyx Cleanse with: NS (normal saline), Pat dry Apply Santyl (an ointment) and Collagen (helps with wound healing), cover with foam dressing every day shift for Wound Healing for 30 days . A review of Resident 1 ' s progress notes and TAR for September 2024, indicated no documented evidence Resident 1 received wound treatment until September 15, 2024. A review of Resident 1's (name of wound specialist) Progress Notes dated September 26, 2024, indicated the sacrococcyx PI was reclassified to stage 4 (full thickness skin and tissue loss that exposes muscle, and bone). On November 4, 2024, at 11:55 a.m., during interview with TXN 2, TXN 2 stated when residents are identified with a wound, she would contact the doctor, would contact the family, and would write a treatment order following the facility wound treatment protocol, the day the wound was identified. TXN 2 verified Resident 1 ' s wound treatment was ordered on September 14, 2024, however; the TAR indicated Resident 1 received sacrococcyx wound treatment on September 15, 2024. (Two days after the PI was discovered). On November 4, 2024, at 1:44 p.m., during an interview with Registered Nurse (RN) 1, who was the Minimum Data Set (MDS - an assessment tool) Coordinator, RN 1 stated the interventions for residents identified as at risk for developing a PI include repositioning, encourage the resident to get out of bed as tolerated, provide moisture barrier cream, peri care, and a pressure reducing mattress. RN 1 stated all residents in the facility are provided with a pressure reducing mattress. RN 1 stated interventions for residents who are moderate and high risk for developing PI would be the same for those who are at risk because once a resident is identified as at risk for developing a PI, they implement all interventions right away to prevent the development of a wound. RN 1 stated the CNAs do not document turning and repositioning of the residents. RN 1 stated CNAs are trained to reposition residents every two hours and it was part of their daily routine. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055409 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 055409 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2024 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 - Actual harm Residents Affected - Few On November 12, 2024, at 10:00 a.m., during a telephone interview with the Director of Staff Development (DSD), the DSD stated when licensed nurses signed the Skin Inspection sheet, they acknowledged the wound or any skin issues reported by the CNA, and they should get a treatment order from the physician. A review of the facility ' s policy and procedure titled Skin Assessment dated 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, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, and weekly thereafter .Documentation of skin assessment .Include date and time of the assessment, your name, and position title .Document observations .type of wound describe wound .document if resident refused assessment and why .other information as indicated or appropriate . A review of the facility's policy and procedure, titled Pressure Injury Prevention and Management, dated December 19, 2022, indicated .the facility shall establish and utilize a systematic approach for pressure injury and prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of interventions; and modifying the interventions as appropriate licensed nurses will conduct a pressure injury risk assessment, using the Braden Scale for Predicting pressure Ulcer Risk, on all residents upon admission/re-admission, weekly time 3 (sic) more weeks, then quarterly or whenever the resident's condition changes significantly .licensed nurses will conduct a full body skin assessment at least weekly after admission/re-admission. Findings will be documented in the medical record .Nursing assistants will inspect skin during bath and will report any concerns to the resident's nurse immediately after the task .after completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions .basic routine care interventions could include, but are not limited to: redistribute pressure. minimize exposure to moisture and keep skin clean .provide appropriate pressure-redistributing, support surfaces .provide non-irritating surfaces; and . maintain or improve nutrition and hydration status, where feasible . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055409 If continuation sheet Page 4 of 4