Inspection·August 4, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete review of Resident 1's progress notes were conducted with LVN 1. LVN 1 stated Resident 1 refused urine collection and had a change in behavior on June 16, 2025. LVN 1 stated, she should have reported Resident 1's refusal and behavior change to the physician. On July 10, 2025, at 1:56 p.m., an interview and record review of Resident 1's progress notes were conducted with Registered Nurse (RN) 1. RN 1 stated the process for treatment refusals was to contact the physician and document in the medical record. RN 1 stated, the physician placed a new order for urinalysis on June 16, 2025. RN 1 stated, the urine sample was not obtained, the refusal should have been documented, and the physician should have been notified. A review of the facility policy titled, Notification of Changes, dated December 2022, indicated, .to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification.examples.recurrent episodes of delirium, recurrent UTIs.significant change in the resident's physical, mental or psychosocial conditions such as deterioration in health, mental or psychosocial status.acute condition.exacerbation of a chronic condition. Event ID: Facility ID: 056162 If continuation sheet Page 2 of 5 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 08/04/2025 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)

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 observation, interview, and record review, the facility failed to ensure care and treatment were provided for four of seven residents reviewed (Residents 1, 4, 5, and 6) when:1. For Resident 1, the licensed nurses did not timely assess and monitor the resident who experienced a change in condition on June 16, 2025. This failure resulted in the hospitalization of Resident 1 on June 20, 2025, with a diagnosis of urinary tract infection (an infection that occurs in any part of the urinary system [how the body gets rid of extra water and waste]). 2. For Residents 4, 5, and 6, peripheral intravenous (IV - administration of fluids or medication through the vein) sites were not documented as assessed or changed for the duration of the admission. This failure had the potential to place Residents 4, 5, and 6 at risk for infection and injury due to prolonged use of the same IV access.Findings: 1 . On July 10, 2025, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses including toxic encephalopathy (a condition of chemical imbalance in the blood) and urinary tract infection. A review of the Care Plan the resident has impaired immunity dated March 26, 2025, indicated, .the resident will remain free from infection through the review date.the resident will not display any complications related to immune deficiency .interventions.monitor/document/report to MD s/sx of delirium: change in behavior, altered mental status, wide variation in cognitive function throughout the day, communication decline, disorientation, periods of lethargy, restlessness, and agitation, altered sleep cycle. A review of Resident 1's Physician Order dated, June 13, 2025, indicated, .U/A (urinalysis) with C/S (a laboratory test used to identify the type of bacteria causing an infection to determine which antibiotics or treatments) for routine lab on Monday AM June 16, 2025. A review of Resident 1's Progress Notes, indicated, -Dated, June 13, 2025, at 9:54 p.m., .Dr.new order for UA with C/S on Monday AM.June 16, 2025 for routine lab.resident aware noted and carried out. -Dated, June 16, 2025, at 2:27 p.m., .patient (Resident 1) refused meds and blood sugar checks this shift.she yelled and attempted hitting at nurse.resident refused to be changed.yelled at nurse when talked to her.patient yelled and tried hitting at nurse.pt was left alone.will endorse to next shift continue to monitor. - Dated, June 20, 2025, at 8:00 a.m., .patient (Resident 1) behavior still not cooperative and refusing meds, treatments, meals, and even supplements ordered and given.also refusing to work with RNA (restorative nursing assistant).MD (Physician) made aware of residents behavior worsening.awaiting call from MD. Dated June 20, 2025, at 4:23 p.m. indicated, .NP (nurse practitioner) came to visit resident.resident observed to be noncompliant with care.MD ordered to have the resident sent out to hospital for further evaluation including doing the urinalysis as the resident refused to have urine collected last time for UA test. -Dated June 26, 2025, at 10:55 p.m. indicated, .readmit patient from (name of hospital) with DX (diagnosis) of UTI.incontinent of bowel and bladder. Further review of Resident 1's progress note indicated no documentation that Resident 1's change in behavior was monitored and assessed on June 16, 2025. On July 10, 2025, at 1:16 p.m., an interview and record review of Resident 1's progress notes were conducted with LVN 1. LVN 1 stated on June 13, 2025, she documented that Resident 1 refused to provide a urine sample for laboratory testing to rule out a possible urinary tract infection. LVN 1 stated Resident 1 was combative, refused care, and refused to do the labs (ordered tests) on June 16, 2025. LVN 1 was unable to describe or was unaware of the mental effects a urinary tract infection could cause in at risk female residents. LVN 1 stated, Resident 1 had a change in mental status on June 16, 2025, which she should have reported to the physician. LVN 1 stated she should have monitored the resident and documented in the progress note. On July 10, 2025, at 2:08 p.m., an interview and record review of Resident 1's progress notes from June Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056162 If continuation sheet Page 3 of 5 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 08/04/2025 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 5 to June 20, 2025, were conducted with the Director of Nursing (DON). The DON stated, Resident 1 had increased confusion and documented refusals of care on multiple occasions. The DON sated, on June 16, 2025, Resident 1 refused and strike staff and that should have been a change in condition. The DON stated, there was no documentation regarding Resident 1's behavior changes. The DON stated there was a risk of further complications for Residents with an infection and it should have been addressed on June 16, 2025, and the staff should not have waited to communicate the change on June 20, 2025. The DON further stated care plans should be revised and updated with changes in condition so that the interventions in place reflect the current status of the residents. 2a. A review of Resident 4's medical record indicated Resident 4 was admitted to the facility on [DATE], with diagnosis which included, metabolic encephalopathy (chemical imbalance in the blood), and urinary tract infection (UTI). The History and Physical Examination, dated June 11, 2025, indicated Resident 4 has fluctuating capacity to understand and make decisions. A review of the hospital Final Discharge Disposition dated June 10, 2025, indicated, .IV (intervascular) access.peripheral.location.R FA (right forearm).date of insertion.June 7, 2025. A review of the skin check note dated, June 10, 2025, at 10:49 p.m. indicated, .noted with iv in right forearm. A review of the physicians order summary dated, June 11, 2025, indicated, .Cefazolin Sodium (antibiotic) injection solution 2 gm (unit of measure), use 2 gram intravenously (into the blood stream) one time a day for sepsis (infection), UTI for 6 weeks. A review of the nurses progress note dated June 12, 2025, at 10:05 p.m., indicated, .On monitoring for new admit, currently on IV antibiotics for UTI. A review of the skilled evaluation dated June 24, 2025, at 6:31 p.m. indicated, .resident currently on antibiotics cefalzolin 2 gm for diagnosis of uti. A review of the Care Plan titled, Resident is on antibiotic therapy (Cefazolin injection r/t sepsis, UTI indicated, .monitor/document/report s/sx (signs and symptoms) of infection r/t diarrhea, itchy, discharge/coating of anus. Further review of Resident 1's progress notes and Medication Administration Record indicated, there was no documented evidence that care, assessment, and monitoring of the IV site to the right hand of Resident 4 was conducted by the staff from June 10, 2025, to June 27, 2025. 2b. A review of Resident 5's medical record indicated Resident 5 was admitted to the facility on [DATE], with diagnosis which included, metabolic encephalopathy (chemical imbalance in the blood), and urinary tract infection (UTI).The History and Physical Examination, dated June 11, 2025, indicated Resident 5 has fluctuating capacity to understand and make decisions. The Progress note dated July 14, 2025, indicated, .Resident on monitoring for IV ABT (antibiotic) E. coli (bacteria) urine. No worsening symptoms noted.will continue to monitor.The Progress note dated July 13, 2025, indicated, .Resident on monitoring for INVanz (antibiotic) injection 1 gram (unit of measure) intravenously one time a day for ESBL (bacterial infection) in urine for 10 days, no discomfort or pain reported.A review of the Physicians Order Summary dated, July 11, 2025, indicated, .Invanz injection 1 gm use 1 gram intravenously one time a day for ESBL in urine for 10 days. Further review of Resident 5's progress notes and Medication Administration Record indicated that the resident's IV site was being monitored or assessed for infection or infusion of antibiotics.2c. A review of Resident 6's medical record indicated Resident 6 was admitted to the facility on [DATE] and readmitted [DATE], with a diagnosis which included UTI, and end stage renal disease (ESRD - a disease of the kidneys).The History and Physical Examination, dated June 13, 2025, indicated Resident 6 did not have capacity to understand and make decisions. The Nursing Progress Note dated July 4, 2025, indicated, .skin assessment done and noted peripheral line on right arm and right hand.A review of the Physicians Order Summary dated, July 4, 2025, indicated, .Cefeprime HCL (antibiotic) intravenous solution use 1 gram intravenously one time a day for PNA (pneumonia - lung infection) for 14 days.Further review of Resident 6's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056162 If continuation sheet Page 4 of 5 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 08/04/2025 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete progress notes and Medication Administration Record (MAR) indicated there was no documented evidence of monitoring, assessment, or documentation that the peripheral IV noted upon admission was assessed from June 4, 2025, to June 14, 2025. On July 14, 2025, at 2:53 p.m., an interview and record review of Residents 4, 5, and 6's MAR were conducted with RN 2. RN 2 stated when caring for residents receiving IV medications, she reviews the physician's orders and assessed the IV site for patency and signs of infection before administering the medication. RN 2 stated, IV sites should be labeled with the insertion date and that peripheral IV lines should typically be checked every two or three days. RN 2 stated she was unsure how long the IV lines can remain in place, and they are usually left in as long as they appear to be functioning and uninfected, unless they become dislodged, stop working, or the resident request to keep it in. RN 2 stated there was no documented evidence in Residents 4, 5, 7, and 7's records indicating the IV sites were assessed, removed, or changed. RN 2 stated, documentation should have been completed. RN 2 stated the facility has a standard order set for IV monitoring, but it was not followed for these residents. RN 2 stated, there was no way to confirm whether the required site assessments were performed. On July 14, 2025, at 3:54 p.m., an interview and record review were conducted with the DON. The DON stated upon admission from another facility or the hospital, all residents with a peripheral IV in place should be assessed each shift. The DON stated, the assessment should include looking for signs of infection, patency, and skin changes. The DON stated he was unsure how long a peripheral IV could remain in place, but IV sites should be labeled with the insertion date. The DON stated, IV site assessments should be documented in the MAR and/or in a progress note to confirm that the assessment was completed. The DON stated the order set for four residents were missing and it should have been in place. The DON stated, the lack of documentation of IV site assessments posed a risk for residents to develop infections and for the insertion site to go unchecked. A review of the facility policy titled, Peripheral Intravenous Catheter Insertion, Maintenance, and Removal dated December 19, 2022, indicated, .it is the policy of this facility to ensure that peripheral intravenous catheters are inserted, maintained and discontinued consistent with current standards of practice.peripheral intravenous (IV) catheter.to maintain an IV access to the resident.peripheral IV sites should be changed after 72 hours unless otherwise ordered by the physician, if the site becomes infiltrated, or if the resident exhibits signs of phlebitis or extravasation.if the IV is left in place longer than 72 hours, IV site care will be done every 24 hours.Peripheral IV sites should be checked at least every shift and PRN.Removal of peripheral IV is indicated by the order of the physician when therapy is complete, when clinically indicated, when deemed no longer necessary for the plan of care, or have not been used for 24 hours or more.site care and maintenance.document procedure. Event ID: Facility ID: 056162 If continuation sheet Page 5 of 5