Inspection·June 23, 2025

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a copy of the notice of transfer/discharge was provided to the State Long-Term Care Ombudsman (assists with conflict resolution and protection of resident rights) prior to the planned discharge date , for two of two sampled residents (Residents 1 and 2). This failure had the potential to violate the resident's rights to appeal their discharge. Findings: On June 3, 2025, at 10:05 a.m., an unannounced visit was conducted at the facility to investigate a complaint on discharges. On June 4, 2025, at 1:50 p.m., during a concurrent interview and record review with the Social Services Director (SSD), the SSD stated the following information for Residents 1 and 2: 1. Resident 1 was admitted to the facility on [DATE], with diagnoses which included pneumonia (lung infection) and sepsis (a systemic infection that triggers a dysregulated host response, leading to life-threatening organ dysfunction). Resident 1 was planned for discharge to home on April 30, 2025. The Notice of Proposed Transfer/Discharge, was provided and acknowledged by Resident 1 on April 29, 2025. A copy of the Notice of Proposed Transfer/Discharge, was sent to the Ombudsman on April 30, 2025, after Resident 1 was discharged from the facility; and 2. Resident 2 was admitted to the facility on [DATE], with diagnoses which included heart failure. Resident 2 was planned for discharge to home on April 30, 2025. The Notice of Proposed Transfer/Discharge, was provided and acknowledged by Resident 2 on April 28, 2025. A copy of the Notice of Proposed Transfer/Discharge, was sent to the Ombudsman on April 30, 2025, after Resident 2 was discharged from the facility. The SSD further stated a copy of the Notice of Proposed Transfer/Discharge, for Residents 1 and 2 should have been provided to the Ombudsman prior to the discharge date of April 30, 2025, to ensure the Ombudsman had an opportunity to discuss with the residents to be discharged of any concerns they have. On June 4, 2025, at 3:32 p.m., during an interview with the Director of Nursing (DON), the DON stated the Case Manager (CM) coordinated all the discharge process. The DON stated the CM should have notified the Ombudsman before the resident leaves the facility. (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 2 Event ID: 055581 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 055581 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jurupa Hills Post Acute 6401 33rd Street. Riverside, CA 92509 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)