Other·August 7, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated standard survey for the investigation of one complaint. Complaint number CA00592981. Representing the California Department of Public Health: Surveyor Federal ID number 38478, HFEN. The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Two deficiencies were issued for complaint number CA00592981.

F660 SS=D Discharge Planning Process CFR(s): 483.21(c)(1)(i)-(ix)

F660 07/18/2018 §483.21(c)(1) Discharge Planning Process The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to postdischarge care, and the reduction of factors leading to preventable readmissions. The facility's discharge planning process must be consistent with the discharge rights set forth at 483.15(b) as applicable and(i) Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident. (ii) Include regular re-evaluation of residents to identify changes that require modification of the LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P6I611 Facility ID: CA240000010 If continuation sheet 1 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055042 (X3) DATE SURVEY COMPLETED 07/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALTA VISTA HEALTHCARE & WELLNESS CENTRE 9020 Garfield St Riverside, CA 92503 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE discharge plan. The discharge plan must be updated, as needed, to reflect these changes. (iii) Involve the interdisciplinary team, as defined by §483.21(b)(2)(ii), in the ongoing process of developing the discharge plan. (iv) Consider caregiver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs. (v) Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan. (vi) Address the resident's goals of care and treatment preferences. (vii) Document that a resident has been asked about their interest in receiving information regarding returning to the community. (A) If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose. (B) Facilities must update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities. (C) If discharge to the community is determined to not be feasible, the facility must document who made the determination and why. (viii) For residents who are transferred to another SNF or who are discharged to a HHA, IRF, or LTCH, assist residents and their resident representatives in selecting a postacute care provider by using data that includes, but is not limited to SNF, HHA, IRF, or LTCH standardized patient assessment data, data on quality measures, and data on resource use to the extent the data is available. The facility must ensure that the post-acute care standardized patient assessment data, data on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P6I611 Facility ID: CA240000010 If continuation sheet 2 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055042 (X3) DATE SURVEY COMPLETED 07/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALTA VISTA HEALTHCARE & WELLNESS CENTRE 9020 Garfield St Riverside, CA 92503 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE quality measures, and data on resource use is relevant and applicable to the resident's goals of care and treatment preferences. (ix) Document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident's representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to implement an effective and safe discharge for one of three sampled residents (Resident A), who was identified as unable to safely administer own medications and required caregiver support with ADLs, was discharged to an unlicensed room and board (a facility that offers to the general public living accommodations and meals). This failure resulted in the unsafe discharge/transition to the community, leading to the readmission of Resident A to the acute care hospital. Findings: On July 3, 2018, an unannounced visit to the facility was conducted to investigate a complaint related to admission, transfer, and discharge. Resident A's record was reviewed. Resident A was admitted to the facility on March 7, 2018, with diagnoses which included dementia (memory loss), hypertension (high blood FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P6I611 Facility ID: CA240000010 If continuation sheet 3 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055042 (X3) DATE SURVEY COMPLETED 07/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALTA VISTA HEALTHCARE & WELLNESS CENTRE 9020 Garfield St Riverside, CA 92503 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE pressure), and cerebrovascular accident (CVAstroke). The history and physical, dated March 11, 2018, indicated, "...this resident does not have the capacity to understand and make decisions..." The "Assessment for Self-Administration of Medications," dated March 7, 2018, indicated the resident was unable to correctly state how much medicine to take for each dose, correctly document self-administration of medications, demonstrate secure storage for medications kept in room, correctly state situations for administration of PRN (as needed) dose, adhere to maximum dose requirements for medication, and describe side effects of medications. The "Social Services Assessment," dated March 8, 2018, indicated, "...Daughter expressed that res. (resident) was recently diagnosed with dementia. Res wants to return to the community per daughter but is unable to care for himself at this time..." The discharge care plan, dated March 8, 2018, indicated, "...Goal: resident will be discharged to lower level of care when rehabilitation goals are met...resident will discharge to lower level of care when medically stable...resident('s) functioning will determine his d/c (discharge) plans..." A physician order, dated May 2, 2018, indicated, "D/C to B&C (board and care- a licensed 24-hour care property, with 24-hour staffing, providing assistance with bathing, dressing, and medication management)..." The minimum data set (MDS- a comprehensive assessment tool), dated May 4, 2018, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P6I611 Facility ID: CA240000010 If continuation sheet 4 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055042 (X3) DATE SURVEY COMPLETED 07/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALTA VISTA HEALTHCARE & WELLNESS CENTRE 9020 Garfield St Riverside, CA 92503 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicated, "...Brief Interview for Mental Status (BIMS - screening test used for mental and cognitive status) score of 7 (a score of 0-7 means severely impaired)..." The "Discharge Summary/Post Discharge Plan of Care," dated May 4, 2018, indicated, "...Functional status: needs assistance: bathing, dressing, personal hygiene, toilet use, ambulation..." The discharge medication orders, dated May 4, 2018, included the following: - "Catapres (medication to control hypertension) 0.1 mg (milligrams), 1 tab (tablet) by mouth every 6 hours as needed for BP (blood pressure) more than 150... - Metoprolol tartrate (medication to control hypertension) 50 mg, 1 tab by mouth 2 times a day... - Tylenol (pain medication) 650 mg by mouth every 6 hours as needed for pain or fever more than 100.5 F (Fahrenheit). Don't take more than 3 grams Tylenol in 24 hours..." The "Nurse's Notes," dated May 4, 2018, at 12:00 p.m., indicated, "Resident for d/c to B&C..." The "Nurse's Notes," dated May 4, 2018, at 2:15 p.m., indicated, "Resident was pick (sic) up by administrator of B&C..." On July 2, 2018, at 8:04 a.m., Resident A's durable power of attorney designee (DPOA), was interviewed. The DPOA stated she was the resident's daughter. The DPOA stated Resident A was discharged to a room and board that was recommended by the facility's Social Worker (SW). The DPOA stated the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P6I611 Facility ID: CA240000010 If continuation sheet 5 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055042 (X3) DATE SURVEY COMPLETED 07/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALTA VISTA HEALTHCARE & WELLNESS CENTRE 9020 Garfield St Riverside, CA 92503 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident was not discharged to the agreedupon address of the room and board in Riverside county. The DPOA stated she found out from the home health nurse that the resident was discharged to the other room and board facility of the same owner in Corona. The DPOA stated she found out during her visit that Resident A ran out of medications for two days. The DPOA stated Resident A had a fall incident while in the room and board facility and was transferred to the acute hospital for further evaluation. On July 3, 2018, at 10:43 a.m., the facility's SW was interviewed regarding Resident A. The SW confirmed Resident A was discharged to a room and board facility on May 4, 2018. The SW stated the room and board covered the meals and no caregivers were available. The SW stated she found out on May 7, 2018 from the DPOA and the home health nurse that Resident A was sent by the administrator of the room and board to a different location. The SW stated she did not know if Resident A was able to check his own blood pressure. The SW stated the room and board was not licensed. On July 3, 2018, at 11:08 a.m., the Registered Nurse (RN) Supervisor was interviewed. The RN Supervisor stated she thought Resident A was discharged to a board and care facility. The RN supervisor stated she did not know Resident A was discharged to a room and board facility. On July 3, 2018, at 11:40 a.m., the Director of Nursing (DON) was interviewed. The DON stated a room and board is a facility for highly functional residents with no caregivers available. The DON stated the board and care is a licensed facility with caregiver assistance with the performance of activities of daily living and medication administration. The DON stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P6I611 Facility ID: CA240000010 If continuation sheet 6 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055042 (X3) DATE SURVEY COMPLETED 07/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALTA VISTA HEALTHCARE & WELLNESS CENTRE 9020 Garfield St Riverside, CA 92503 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE that with Resident A's condition, it would have been "more appropriate" for a discharge placement in a board and care than in a room and board facility. On July 12, 2018, at 10:16 a.m., the owner of the room and board (R&B) facility was interviewed. The owner of the R&B stated the facility was not licensed and did not have caregiving services available. The owner of the R&B stated they only provided services such as meals, laundry, and cleaning of the rooms. The owner of the R&B stated they did not provide medications to the residents and that the residents handle their own medications. The owner of the R&B stated Resident A had a fall incident in the patio of the facility and was transferred via 911 ambulance to the acute care hospital. The facility's policy and procedure titled, "Transfer and Discharge," dated October 2017, indicated: "Purpose: To ensure that adequate preparation and assistance is provided to residents prior to transfer or discharge from the facility. ...Discharge planning will begin on the resident's admission to the facility. ...If the IDT team and the Attending Physician determine that the resident may be appropriate for discharge, Social Services Staff will coordinate the discussion of discharge with IDT, the resident, and the responsible party. ...Social Services staff will communicate with Facility Staff, the resident and responsible party as the time for discharge approaches..."

F745 SS=D Provision of Medically Related Social Service CFR(s): 483.40(d) FORM CMS-2567(02-99) Previous Versions Obsolete

F745 Event ID: P6I611 07/18/2018 Facility ID: CA240000010 If continuation sheet 7 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055042 (X3) DATE SURVEY COMPLETED 07/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALTA VISTA HEALTHCARE & WELLNESS CENTRE 9020 Garfield St Riverside, CA 92503 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.40(d) The facility must provide medicallyrelated social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility's social worker (SW) failed to ensure, for one of three sampled residents (Resident A), appropriate and sufficient discharge transition assistance was provided to the resident. This failure resulted in the unsafe discharge of Resident A to an unlicensed room and board (a facility that offers to the general public living accommodations and meals), leading to the resident's readmission to the acute care hospital. Findings: On July 3, 2018, an unannounced visit to the facility was conducted to investigate a complaint related to admission, transfer, and discharge. Resident A's record was reviewed. Resident A was admitted to the facility on March 7, 2018, with diagnoses which included dementia (memory loss), hypertension (high blood pressure), and cerebrovascular accident (CVAstroke). The history and physical, dated March 11, 2018, indicated, "...this resident does not have the capacity to understand and make decisions..." The "Assessment for Self-Administration of Medications," dated March 7, 2018, indicated the resident was unable to correctly state how much medicine to take for each dose, correctly FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P6I611 Facility ID: CA240000010 If continuation sheet 8 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055042 (X3) DATE SURVEY COMPLETED 07/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALTA VISTA HEALTHCARE & WELLNESS CENTRE 9020 Garfield St Riverside, CA 92503 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE document self-administration of medications, demonstrate secure storage for medications kept in room, correctly state situations for administration of PRN (as needed) dose, adhere to maximum dose requirements for medication, and describe side effects of medications. The "Social Services Assessment," dated March 8, 2018, indicated, "...Daughter expressed that res. (resident) was recently diagnosed with dementia. Res wants to return to the community per daughter but is unable to care for himself at this time..." The discharge care plan, dated March 8, 2018, indicated, "...Goal: resident will be discharged to lower level of care when rehabilitation goals are met...resident will discharge to lower level of care when medically stable...resident('s) functioning will determine his d/c (discharge) plans..." A physician order, dated May 2, 2018, indicated, "D/C to B&C (board and care- a licensed 24-hour care property, with 24-hour staffing, providing assistance with bathing, dressing, and medication management)..." The minimum data set (MDS- a comprehensive assessment tool), dated May 4, 2018, indicated, "...Brief Interview for Mental Status (BIMS - screening test used for mental and cognitive status) score of 7 (a score of 0-7 means severely impaired)..." The "Discharge Summary/Post Discharge Plan of Care," dated May 4, 2018, indicated, "...Functional status: needs assistance: bathing, dressing, personal hygiene, toilet use, ambulation..." The discharge medication orders, dated May 4, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P6I611 Facility ID: CA240000010 If continuation sheet 9 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055042 (X3) DATE SURVEY COMPLETED 07/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALTA VISTA HEALTHCARE & WELLNESS CENTRE 9020 Garfield St Riverside, CA 92503 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2018, included the following: - "Catapres (medication to control hypertension) 0.1 mg (milligrams), 1 tab (tablet) by mouth every 6 hours as needed for BP (blood pressure) more than 150... - Metoprolol tartrate (medication to control hypertension) 50 mg, 1 tab by mouth 2 times a day... - Tylenol (pain medication) 650 mg by mouth every 6 hours as needed for pain or fever more than 100.5 F (Fahrenheit). Don't take more than 3 grams Tylenol in 24 hours..." The "Nurse's Notes," dated May 4, 2018, at 12:00 p.m., indicated, "Resident for d/c to B&C..." The "Nurse's Notes," dated May 4, 2018, at 2:15 p.m., indicated, "Resident was pick (sic) up by administrator of B&C..." On July 2, 2018, at 8:04 a.m., Resident A's durable power of attorney designee (DPOA), was interviewed. The DPOA stated she was the resident's daughter. The DPOA stated Resident A was discharged to a room and board that was recommended by the facility's Social Worker (SW). The DPOA stated the resident was not discharged to the agreedupon address of the room and board in Riverside county. The DPOA stated she found out from the home health nurse that the resident was discharged to the other room and board facility of the same owner in Corona. The DPOA stated she found out during her visit that Resident A ran out of medications for two days. The DPOA stated Resident A had a fall incident while in the room and board facility and was transferred to the acute hospital for further evaluation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P6I611 Facility ID: CA240000010 If continuation sheet 10 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055042 (X3) DATE SURVEY COMPLETED 07/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALTA VISTA HEALTHCARE & WELLNESS CENTRE 9020 Garfield St Riverside, CA 92503 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On July 3, 2018, at 10:43 a.m., the facility's SW was interviewed regarding Resident A. The SW confirmed Resident A was discharged to a room and board facility on May 4, 2018. The SW stated the room and board covered the meals and no caregivers were available. The SW stated she found out on May 7, 2018 from the DPOA and the home health nurse that Resident A was sent by the administrator of the room and board to a different location. The SW stated she did not know if Resident A was able to check his own blood pressure. The SW stated the room and board was not licensed. On July 3, 2018, at 11:08 a.m., the Registered Nurse (RN) Supervisor was interviewed. The RN Supervisor stated she thought Resident A was discharged to a board and care facility. The RN supervisor stated she did not know Resident A was discharged to a room and board facility. On July 3, 2018, at 11:40 a.m., the Director of Nursing (DON) was interviewed. The DON stated a room and board is a facility for highly functional residents with no caregivers available. The DON stated the board and care is a licensed facility with caregiver assistance with the performance of activities of daily living and medication administration. The DON stated that with Resident A's condition, it would have been "more appropriate" for a discharge placement in a board and care than in a room and board facility. On July 12, 2018, at 10:16 a.m., the owner of the room and board (R&B) facility was interviewed. The owner of the R&B stated the facility was not licensed and did not have caregiving services available. The owner of the R&B stated they only provided services such as meals, laundry, and cleaning of the rooms. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P6I611 Facility ID: CA240000010 If continuation sheet 11 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055042 (X3) DATE SURVEY COMPLETED 07/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALTA VISTA HEALTHCARE & WELLNESS CENTRE 9020 Garfield St Riverside, CA 92503 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The owner of the R&B stated they did not provide medications to the residents and that the residents handle their own medications. The owner of the R&B stated Resident A had a fall incident in the patio of the facility and was transferred via 911 ambulance to the acute care hospital. The facility's policy and procedure titled, "Transfer and Discharge," dated October 2017, indicated: "Purpose: To ensure that adequate preparation and assistance is provided to residents prior to transfer or discharge from the facility. ...Discharge planning will begin on the resident's admission to the facility. ...If the IDT team and the Attending Physician determine that the resident may be appropriate for discharge, Social Services Staff will coordinate the discussion of discharge with IDT, the resident, and the responsible party. ...Social Services staff will communicate with Facility Staff, the resident and responsible party as the time for discharge approaches..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P6I611 Facility ID: CA240000010 If continuation sheet 12 of 12