Health inspection·July 16, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 8:15 a.m. to 8:30 a.m. Resident 4 stated her blood sugar could drop if insulin is being administered earlier than ordered by the physician. A review of Resident 4's admission Record, indicated Resident 4 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus. A review of Resident 4's MDS, dated [DATE], indicated a BIMS score of 15. A review of Resident 4's Order Summary Report, included a physician's order, dated July 11, 2025, which indicated, .Novolog (short acting insulin) Injection solution 100 UNIT/ML .Inject 3 (three) unit .before meals .On July 16, 2025, at 6:30 a.m., during an interview with LVN 2, she stated she started 6:30 a.m. med pass at 4:30 a.m. because she would not be able to finish med pass on time before her shift ends. LVN 2 stated they used to have four (4) LVNs for med pass with 27 - 29 residents each but now they only have three (3) LVNs and had 36 - 38 patients each. LVN 2 stated when they had four LVNs, they were able to start and finish on time for medication pass.On July 16, 2025, at 6:47 a.m., during an interview with Registered Nurse Supervisor (RNS), he stated the LVNs would start their medication pass at around 4:30 a.m. so they could finish on time. On July 16, 2025, at 8:14 a.m., a follow up interview was conducted with LVN 1, she stated when medications were administered earlier than scheduled times, the physician should have been notified. On July 16, 2025, at 8:28 a.m., during a concurrent observation and interview, Resident 2 was in her room, lying in bed and awake. Resident 2 did not respond to interview questions. Resident 2's breakfast tray was observed on the overbed table. A review of Resident 2's admission Record, indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which indicated diabetes mellitus. A review of Resident 2's Order Summary Report, included a physician's order, dated July 2, 2025, indicated, .Insulin Glargine .Inject 25 unit .in the morning .On July 16, 2025, at 8:32 a.m., during a concurrent observation and interview with Resident 1 in her room, alert, awake and sitting in her wheelchair. Resident 1 stated she received medications at 4 a.m., but she did not know which medication it was, and she could not remember when it happened.A review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included hypothyroidism and gastric ulcer (an open sore or raw area in the lining of the stomach). A review of Resident 1's Order Summary Report, included the following physician's order:-Omeprazole Capsule Delayed Release 20 MG (milligram - unit of measurement), Give 2 (two) capsule by mouth in the morning .Administer on an empty stomach, 30 minutes before breakfast ., date ordered December 28, 2024; and-Synthroid (thyroid medication) Oral Tablet 25 MCG .Give 1 (one) tablet by mouth in the morning ., date ordered December 31, 2024.A review of Resident 1's MDS, dated [DATE], indicated a BIMS score of 12 (cognitively intact).On July 16, 2025, at 9:30 a.m., during a concurrent interview with the Director of Staff Development (DSD) and record review of Resident 1, 2, and 4's physician's orders, the DSD stated if a medication was scheduled to be given at a certain time, it should be administered at the specified time. The DSD stated PCC would not allow the charge nurses to sign for med pass too early or too late. On July 16, 2025, at 10:01 a.m., during an interview with the Assistant Director of Nursing (ADON), she stated if a medication was scheduled to be administered at 6:30 a.m., the charge nurses should administer the medication one hour before or one hour after. The ADON stated if the charge nurse gave a medication earlier than what was allowed, the charge nurse needs to notify the physician. The ADON stated the charge nurses were not allowed to decide to give a medication early just because they have a lot to do.On July 16, 2025 at 12:42 p.m., during an interview with the Nurse Consultant (NC) and the Administrator (ADM), the NC stated the RN should be assessing if the LVNs were late with their med pass and step in to alleviate the pressure and the LVNs should administer the medications as ordered by the physician within the scheduled time, an hour before and an hour after.A review of the facility's policy and procedure titled Medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055474 If continuation sheet Page 2 of 3 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 055474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodcrest Post Acute & Rehabilitation 8133 Magnolia Avenue Riverside, CA 92504 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 0755 Level of Harm - Minimal harm or potential for actual harm Administration Schedule, dated July 2024, indicated, .Scheduled medications are administered within one (1) hour of their prescribed time, unless otherwise specified .The exact time of medication administration is documented in the MAR. If medication is administered early .the reason is also documented . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055474 If continuation sheet Page 3 of 3