Health inspection·February 21, 2025

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed, for one of four residents (Resident 1), to ensure the Office of the State Long-Term Care Ombudsman (LTC Ombudsman - an advocate for residents to protect residents' rights and ensure quality care) received timely notification of Proposed Transfer/Discharge (a planned or suggested move of a resident from a healthcare facility to another location) when Resident 1 was discharged on January 31, 2025. This failure has the potential to result in Resident 1 lacking an advocate to protect their rights and ensure an appropriate and safe discharge plan. Findings: Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses including esophageal cancer (a rare cancer that occurs when cells in the esophagus is a muscular tube that moves food and liquids from the throat to the stomach mutate and grow out of control). A review of Resident 1's History and Physical, dated October 14, 2024, indicated Resident 1 had the capacity to understand and make decisions. A review of the Physician Order, dated January 30, 2025, indicated Resident 1 was to be discharged to (Name of facility). A review of the Notice of Proposed Transfer/Discharge, dated January 29, 2025, indicated that Resident 1 had given verbal consent to the Proposed Transfer/Discharge plan. The Notice of Proposed Transfer/Discharge form included a fax transmittal dated February 3, 2025, at 1:22 p.m., sent to the Ombudsman, four days after Resident 1 was discharged . A review of the Nurse Progress Note, dated January 31, 2025, indicated that Resident 1 had been discharged to (Name of Facility). On February 3, 2025, at 1:26 p.m., a concurrent record review and interview was conducted with the SSD. The SSD stated, Resident 1 had given a verbal consent to the Notice of Proposed Transfer/ Discharge on January 29, 2025. The SSD stated she had not notified the LTC Ombudsman until February 3, 2025. The SSD stated she should have faxed the notice to the LTC Ombudsman on January 29, 2025, when Resident 1 received the discharge notice. The SSD stated the protocol for a planned discharge had been to notify the resident and (Named (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: 056162 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 056162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Extended Care Hospital of Riverside 8171 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)