Health inspection·August 8, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 did not ensure that new medical orders were implemented in a timely manner after an orthopedic (specialty focusing on musculoskeletal system) consultation for one of one resident (Resident 2) reviewed. This failure caused a delay in treatment and services for Resident 2.Findings:On August 6, 2025, at 9:50 a.m., Resident 2 was interviewed. Resident 2 stated that his right arm was broken. Resident 2 stated that he needed to have an order from the Medical Doctor (MD) to start therapy exercises on his right arm. Resident 2 further stated that he has not had any physical therapy (PT) on his right arm since he was admitted to the facility.On August 6, 2025, at 9:45 a.m., Resident 2's medical record was reviewed. Resident 2 was admitted on [DATE], with a primary diagnosis of unspecified displaced fracture of surgical neck of right humerus (fractured upper arm bone).A review of Resident 2's, History and Physical, dated June 7, 2025, indicated Resident 2 had the capacity to understand and make decisions.A review of Resident 2's, Order Summary Report, as of August 6, 2025, indicated Resident 2 had a follow up orthopedic consult on July 30, 2025, at 11 a.m. In addition, Resident 2 had a physician's order, dated June 8, 2025, to have an arm sling to right arm to immobilize and support the arm in a comfortable position to reduce movement at the fracture site of humeral (upper arm bone).Resident 2 did not have a current active order for therapy exercises on his right arm.A review of Resident 2's, Progress Notes, dated July 30, 2025, indicated Resident 2 went out for orthopedic appointment at approximately 10 a.m. and returned to the facility at approximately 1 p.m. the same day.There was no documentation of evidence that the facility had followed up with the orthopedic doctor for new orders or recommendations that had been given for Resident 2 when he went out for his appointment with the orthopedic doctor on July 30, 2025.On August 6, 2025, at 11:05 a.m., Occupational Therapist Assistant (OTA) 1 was interviewed. OTA 1 stated Resident 2's arm had a sling, so she did arm exercises to his left arm only. OTA 1 further stated Resident 2 was admitted with a broken right arm and he should be reassessed if he needed an exercise therapy to his right arm.On August 6, 2025, at 3:30 p.m. an interview was conducted with Social Service Assistant (SSA) 1. SSA 1 stated Resident 2 had an orthopedic appointment on July 30, 2025, but there was no documentation pertaining to the visit. The SSA 1 further stated if there was no documentation of the visit, it could lead to complications and cause delays in the care or attention that Resident 2 needed. On August 7, 2025, at 2:49 p.m., an interview with a concurrent record review was conducted with SSA 1. A review of Resident 2's, Referral Letter, dated and signed by the Medical Doctor (MD) on August 7, 2025, indicated, .Reason for Referral.physical therapy for elbow and wrist 12 session.Start Date.07/31/2025.In a concurrent interview, SSA 1 stated the Physical Therapy (PT) orders (referring to the Referral Letter) from the orthopedic consultation on July 30, 2025, for the right arm were received on August 7, 2025. SSA 1 stated when a resident was sent out for an appointment, they were supposed to come back with an AVS (After Visit Summary). SSA 1 stated Resident 2 did not have an AVS when he came Residents Affected - Few Page 1 of 5 055581 055581 08/08/2025 Jurupa Hills Post Acute 6401 33rd Street. Riverside, CA 92509

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few back from his appointment on July 30, 2025.On August 7, 2025, at 4:30 p.m., an interview with a concurrent record review was conducted with the Director of Nursing (DON). The DON stated the following:- The facility staff expects an AVS when a resident returns from an appointment and the social services and nursing were expected to follow up on the results from the consultation; - Resident 2 went out for a follow up appointment with the orthopedic doctor on July 30, 2025. The SSD did not document anything about the following up on the orthopedic doctor recommendation for Resident 2 up until August 6, 2025;- The orthopedic doctor's new orders for exercises to the right arm was ordered on July 31, 2025, and there was a seven-day delay in implementing this new order; and- The lack of follow-up on new recommendations from the doctor resulted in a delay in services for the resident and it was not acceptable.A review of Resident 2's (name of orthopedic office) consultation notes, dated July 30, 2025, indicated, .Chief Complaint.Right shoulder.Impression.IMPACTED RIGHT PROXIMAL HUMERAL NECK FRACTURE.Treatment.Referral To: Physical Therapist.Reason: physical therapy for elbow and wrist 12 sessions.Follow up.2 Weeks (Reason: repeat x-rays elbow and wrist.The facility was not able to provide their policy and procedure on following up new orders or recommendations from a consulting doctor for residents who went out for a specialty doctor appointment. 055581 Page 2 of 5 055581 08/08/2025 Jurupa Hills Post Acute 6401 33rd Street. Riverside, CA 92509

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure, for one of three residents (Resident 1):1. An environment free from accident hazards, when a resident (Resident 1) was able to gain access and ingest a packet of hydrocortisone (steroid ointment) without the staff knowledge. This failure resulted in the hydrocortisone packet getting lodged to the resident's throat causing the resident to choke while eating, which could subsequently obstruct the resident's airway leading to a loss of consciousness and death. Resident 1 was transferred to the general acute hospital (GACH), for evaluation and treatment; and2. The incident related to finding the hydrocortisone packet lodged in the resident's throat was thoroughly investigated. This failure placed the resident at risk of recurrence and further harm. Findings:On August 7, 2025, at 9:28 a.m., an observation was conducted with Resident 1. Resident 1 was observed sitting in a wheelchair in the dining room. Resident 1 was alert but not responding to interviews.On August 7, 2025, Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included right side hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of body), and dementia (memory loss).A review of Resident 1's Progress Notes, dated July 30, 2025, indicated Resident 1 did not have the capacity to understand and make decisions.A review of Resident 1's Minimum Data Set (MDS - an assessment tool), dated May 11, 2025, indicated Resident 1 had a BIM (Brief Interview for Mental Status) Score of 3 (meant severe cognitive impairment). The MDS data further indicated Resident 1 was non-ambulatory and needed .substantial/maximal assistance. on eating and oral hygiene.A review of Resident 1's Care Plan Report, indicated the following:- On July 2, 2023, .Focus.Resident 1 at risk for aspiration (breathing in a foreign object) r/t (related to) difficulty in swallowing.Goal.Utilize aspiration precautions and swallow safely. The care plan indicated this Focus was resolved on August 26, 2024;- On August 7, 2025, Resident 1 had .history of putting uneatable items in mouth and choking.episode 7/2/2023 (July 2, 2023).episode 7/31/2025 (July 31, 2025). The care plan was initiated and created on August 7, 2025.Further review of Resident 1's care plan indicated there was no active care plan addressing aspiration or history of putting uneatable items in mouth before the episode on July 31, 2025. A review of Resident 1's, .Change in Condition Evaluation. dated July 31, 2025, at 10:18 a.m., indicated, .Signs & (and) Symptoms Identified.other change in condition.unknown substance lodged in throat.Functional Status Evaluation.Swallowing Difficulty.Describe the swallowing difficulty.Associated with new onset or progressive choking, aspiration.A review of Resident 1's, Progress Notes, dated July 31, 2025, indicated the Resident 1 was transferred to the GACH by the paramedics (a person trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital ) on July 31, 2025, at 10:41 a.m. A review of Resident 1's GACH emergency room progress notes, dated July 31, 2025, indicated, .Patient Visit Information.You were seen today for.H/O (history of) swallowed foreign body.FOREIGN BODY REMOVAL FROM BACK OF THROAT.WE REMOVED A HYDROCORTISONE PACKET FROM THE BACK OF PATIENT'S THROAT.Foreign Object in Throat, Removed.Objects that are swallowed can get stuck in the throat.A stuck object can cause coughing, choking, pain when swallowing, or trouble swallowing.A review of Resident 1's GACH document titled, .HPI (history of present illness) General Illness, dated July 31, 2025, at 11:22 a.m., indicated:- .Chief Complaint Swallowed a foreign body, possibly a packet of sugar.The patient has some kind of foreign body located in the posterior pharynx (cavity behind nose and mouth) it is unclear what it is at this time. Because the patient's dementia, he is unable to follow directions I am unable to remove it at this time without sedation (administer sedative drug to produce sleep or state of calm).Procedural 055581 Page 3 of 5 055581 08/08/2025 Jurupa Hills Post Acute 6401 33rd Street. Riverside, CA 92509

F 0689 Level of Harm - Actual harm Residents Affected - Few Sedation Note.Once the patient was adequately sedated, I was able to open the patient's mouth and pulled out a small medication packet from the back of his throat. It was a packet of hydrocortisone.A review of Resident 1's Progress Notes, at the Skilled Nursing Facility (SNF), dated July 31, 2025, at 3:50 p.m., indicated Resident 1 returned to the facility from the GACH.A review of Resident 1's Order Summary Report, at the SNF, for the month of August 2025, indicated Resident 1 did not have a current order for a hydrocortisone treatment.Further review of Resident 1's record indicated there was no documented evidence of an investigation conducted to determine the cause of the incident resulting in finding a foreign object (hydrocortisone packet) in Resident 1's mouth on July 31, 2025. In addition, there was no documented evidence that the facility initiated or developed a care plan to address or prevent the incident from re-occurring since July 31, 2025.On August 7, 2025, at 10:36 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated the following:- On July 31, 2025, he saw Resident 1 in bed at around 7 a.m., and he did not notice anything unusual;- While he was passing medications on July 31, 2025, Certified Nursing Assistant (CNA) 1 alerted him that there was something lodged in Resident 1's throat while she was trying to feed him;- He could not tell what it was and tried to suction (a procedure of mechanically removing secretions, like mucus or other fluids, from a patient's airway) and get it out of Resident 1's mouth; - He called (name of an ambulance company) to send Resident 1 out to the hospital. LVN 1 stated the hospital later informed the facility it was a hydrocortisone packet lodged in Resident 1's throat; Resident 1 did not have a current order for hydrocortisone treatment; - Resident 1 did not have a behavior of putting things into his mouth. LVN 1 stated Resident 1 can grab things, but he was wheelchair bound (non-ambulatory) and bed bound (confined in bed due to disability making it difficult or impossible to move around or leave bed);- It was not acceptable that a hydrocortisone packet was found lodged in Resident 1's throat;- The hydrocortisone packet lodged in Resident 1's throat could impact his breathing and could cause discomfort, and placed the resident's life in danger; - The incident could have been prevented by making sure Resident 1's environment was clear of choking hazards; and- Maintaining Resident 1 on close monitoring.On August 7, 2025, at 10:55 a.m., an interview was conducted with CNA 1 and she stated the following: - She was the CNA assigned to render care to Resident 1 on July 31, 2025. Resident 1 was a feeder (someone that requires assistance with being fed during meals); - She was assisting Resident 1 to eat when observed Resident 1 choking. Resident 1 was typically able to clear out his airway and cough;She informed LVN 1 of the resident's situation and Resident 1 was transferred to the GACH; and - Resident 1 did not have a behavior of putting things in his mouth and it was not acceptable for Resident 1 to have something lodged in his throat. On August 8, 2025, at 1 p.m., a concurrent interview and record review was conducted with Treatment Nurse (TN) 1. TN 1 stated that she was the Licensed Nurses (LN) providing skin and wound treatment at Resident 1's station. TN 1 stated that the hydrocortisone medication was stored in a locked cart and at the central supply room, and there was no possibility a CNA or resident would have access to the hydrocortisone packet. On August 7, 2025, at 4:30 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated the following: - Resident 1 had a change of condition on July 31, 2025, when Resident 1 was kinda choking. There was something in Resident 1's throat and staff thought it was a piece of paper and could not remove it; - She was not aware it was a hydrocortisone packet lodged in Resident 1's throat, and she thought it was a sugar packet; - Resident 1 was transferred to the GACH on the morning of July 31, 2025 and returned in the afternoon the same day; - Resident 1 had a history of grabbing and shoving uneatable items in his mouth and the staff were not aware of this behavior. This behavior history was not relayed to the staff;- She did not investigate to determine the cause of Resident 1's 055581 Page 4 of 5 055581 08/08/2025 Jurupa Hills Post Acute 6401 33rd Street. Riverside, CA 92509

F 0689 Level of Harm - Actual harm Residents Affected - Few ingesting a hydrocortisone packet when it happened on July 31, 2025. The facility should have investigated the incident for Resident 1's sake and the sake of others. The DON stated regardless of what it was, the facility should have figured out why the incident happened. The DON stated the consequence of not investigating the cause of the incident in a timely manner had the potential for a re-occurrence and may cause an ill effect on Resident 1. The DON stated she should have investigated the cause of the incident the next day (August 1, 2025); - There had been no changes in Resident 1's care plan since the incident on July 31, 2025. There was no care plan addressing the incident of a hydrocortisone packet found lodged in Resident 1's throat, on July 31, 2025. There should be a care plan to address the incident to prevent recurrence. The facility's policy and procedure titled, Accidents and Incidents - Investigating and Reporting, dated July 2017, was reviewed. The policy indicated, .The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident.The nurse supervisor/charge nurse and/or department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the director of nursing services within 24 hours of the incident or accident.Incident/accident reports will be reviewed by the safety committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities .A review of the facility's policy and procedure titled, Medication Labeling and Storage, revised February 2023, indicated, .The facility stores all medications.in locked compartment.Only authorized personnel have access to keys.The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications.are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. 055581 Page 5 of 5