Other·November 20, 2018

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following represents the findings of the California Department of Public Health during an abbreviated standard survey for the investigation of one complaint with multiple allegations. Complaint number : CA00601007. Representing the California Department of Public Health: Surveyor 29337, HFEN. The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Four deficiencies were issued for complaint number CA00601007.

F558 SS=D Reasonable Accommodations Needs/Preferences CFR(s): 483.10(e)(3)

F558 10/25/2018 §483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide for Resident 1, a room close to the nurses station. This failure did not allow for close and frequent monitoring of the confused and non-compliant, Resident 1. Findings: 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: RZ0F11 Facility ID: CA240000043 If continuation sheet 1 of 13 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: _______________ 055409 (X3) DATE SURVEY COMPLETED 09/25/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COMMUNITY CARE AND REHABILITATION CENTER 4070 Jurupa Ave Riverside, CA 92506 (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 September 6, 2018, an unannounced visit was made to the facility for the investigation of one complaint with multiple allegations. The record for Resident 1 was reviewed. Resident 1 was admitted to the facility from the acute care hospital, on August 16, 2018, for rehabilitation. Resident 1 was admitted with diagnoses that included cerebral hemorrhage, difficulty in walking, muscle weakness, and confusion. The Medication Administration Record (MAR) for the month of August 2018, was reviewed and indicated Resident 1 was taking Seroquel 25 milligrams by mouth daily at bedtime for acute psychotic disorder manifested by continuous calling out. The MAR indicated a side effect of Seroquel was cognitive impairment of increased confusion. This side effect was monitored and was documented 18 times in three days (August 17-19, 2018). The Resident Admission Assessment document, dated August 16, 2018 at 5 p.m., was reviewed and the admitting nurse documented Resident 1 was admitted, to Room 305 A, in a confused state. The Nurses Notes dated August 17 through 23, 2018, were reviewed. There were multiple entries documenting Residents 1's behavior as confused, inappropriate, and needing continuous re-direction. The Resident Care Plan (CP) titled "At Risk for Falls/Injuries R/T (related to)," dated August 17, 2018, was reviewed. The CP indicated Resident 1 was at risk for falls due to poor balance, poor safety awareness, impaired decision making, medications x three with side effects of confusion, and elevated ammonia FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RZ0F11 Facility ID: CA240000043 If continuation sheet 2 of 13 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: _______________ 055409 (X3) DATE SURVEY COMPLETED 09/25/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COMMUNITY CARE AND REHABILITATION CENTER 4070 Jurupa Ave Riverside, CA 92506 (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 levels causing increasing confusion. Two of the interventions for the CP were to "Observe frequently for safety" and "Observe for side effects of medications". On August 18, 2018, an updated intervention was added to the CP. The intervention was for "frequent visual checks and anticipate needs". The Physician's History and Physical, dated August 18, 2018, was reviewed and the symptom of confusion was documented three times. The Laboratory Report, dated August 19, 2018, was reviewed. The report indicated a high ammonia level of 99 umol/L (unit of measure). The normal range for ammonia is 16-53 umol/L. A symptom of an elevated ammonia level is confusion. The Physician's Progress Note, dated August 20, 2018, was reviewed and documented confusion as number one on Resident 1's list of diagnoses. On August 23, 2018, Resident 1 was found on the floor of his room, complaining of severe pain to both his lower extremities and his neck and head. Resident 1 was transferred to the acute care hospital for assessment and treatment and was re-admitted (seven days after discharge for the acute care hospital). The facility layout/map was reviewed. Resident 1's room, 305 A, was located around the corner and across the atrium/patio from the nurses station. On September 6, 2018, at 2 p.m., the Director of Nurses (DON) was interviewed. The DON stated, "It is facility practice to put residents with fall risks nearest to the nurses station." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RZ0F11 Facility ID: CA240000043 If continuation sheet 3 of 13 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: _______________ 055409 (X3) DATE SURVEY COMPLETED 09/25/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COMMUNITY CARE AND REHABILITATION CENTER 4070 Jurupa Ave Riverside, CA 92506 (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 DON stated close to the nurses station is not always possible and subject to room availability.

F580 SS=D Notify of Changes (Injury/Decline/Room, etc.) CFR(s): 483.10(g)(14)(i)-(iv)(15)

F580 10/25/2018 §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is(A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RZ0F11 Facility ID: CA240000043 If continuation sheet 4 of 13 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: _______________ 055409 (X3) DATE SURVEY COMPLETED 09/25/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COMMUNITY CARE AND REHABILITATION CENTER 4070 Jurupa Ave Riverside, CA 92506 (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 representative(s). §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c) (9). This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to notify Resident 1's family immediately upon an acute change of condition (fall) and subsequent transfer to the acute care hospital. Findings: On August 31, 2018, at 1:45 p.m., the complainant reported to the surveyor, by telephone interview, the family was not notified of Resident 1's fall during the early morning hours on August 23, 2018, or his subsequent transfer to the acute care hospital. Resident 1's family visited the facility on the morning of August 23, 2018, and observed the curtains drawn around Resident 1's bed. The family assumed the resident was in the therapy room and inquired further at the nurses station. The staff member informed the family 911 (emergency dispatch) had been called for Resident 1 and he was transferred to the hospital. The complainant stated the staff member stated the emergency medical technicians (EMT's) or the hospital emergency room staff were responsible for communicating the transfer to Resident 1's family. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RZ0F11 Facility ID: CA240000043 If continuation sheet 5 of 13 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: _______________ 055409 (X3) DATE SURVEY COMPLETED 09/25/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COMMUNITY CARE AND REHABILITATION CENTER 4070 Jurupa Ave Riverside, CA 92506 (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 September 6, 2018, an unannounced visit was made to the facility for the investigation of one complaint with multiple allegations. The record for Resident 1 was reviewed. Resident 1 was admitted to the facility from the acute care hospital, on August 16, 2018, for rehabilitation. Resident 1 was admitted with diagnoses that included cerebral hemorrhage, difficulty in walking, muscle weakness, and confusion. The Nurses Notes, dated August 23, 2018, at 4 a.m., were reviewed. There was documentation of resident 1's fall with injury and that the physician was made aware. The physician ordered for resident 1 to be transported to the hospital for further evaluation. There was no documentation Resident 1's family was notified of the fall with injury or the subsequent transfer to the acute care hospital. The Record of Admission, dated August 16, 2018, was reviewed and indicated the names and phone numbers of one "Resident Representative" and two "Next of Kin" are listed. The Care Plan (CP) titled, "At Risk for Falls/Injuries ...," dated August 17, 2018, was reviewed and indicated, "... Notify MD (medical doctor) and family of falls ...". On September 6, 2018, at 2:45 p.m., the Director of nurses (DON) was interviewed. The DON stated, "... Have to notify family regardless of time of day or night of transfer to the hospital and should be documented nursing notes. Not the responsibility of the EMT's or emergency room staff." The DON confirmed there was no FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RZ0F11 Facility ID: CA240000043 If continuation sheet 6 of 13 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: _______________ 055409 (X3) DATE SURVEY COMPLETED 09/25/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COMMUNITY CARE AND REHABILITATION CENTER 4070 Jurupa Ave Riverside, CA 92506 (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 documentation, by the nurse, in Resident 1's record, the family had been notified.

F623 SS=D Notice Requirements Before Transfer/Discharge CFR(s): 483.15(c)(3)-(6)(8)

F623 10/25/2018 §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State LongTerm Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RZ0F11 Facility ID: CA240000043 If continuation sheet 7 of 13 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: _______________ 055409 (X3) DATE SURVEY COMPLETED 09/25/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COMMUNITY CARE AND REHABILITATION CENTER 4070 Jurupa Ave Riverside, CA 92506 (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 needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RZ0F11 Facility ID: CA240000043 If continuation sheet 8 of 13 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: _______________ 055409 (X3) DATE SURVEY COMPLETED 09/25/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COMMUNITY CARE AND REHABILITATION CENTER 4070 Jurupa Ave Riverside, CA 92506 (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 must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l). This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide documented evidence the local ombudsman office was notified timely of Resident 1's transfer to and subsequent admission to the acute care hospital. Findings: On September 6, 2018, an unannounced visit was made to the facility for the investigation of one complaint with multiple allegations. The record for Resident 1 was reviewed. Resident 1 was admitted to the facility from the acute care hospital, on August 16, 2018, for rehabilitation. Resident 1 was admitted with diagnoses that included cerebral hemorrhage, difficulty in walking, muscle weakness, and confusion. On August 23, 2018, Resident 1 fell in his room at the facility in the early morning hours. Resident 1 sustained injuries from the fall and was subsequently transferred and re-admitted, the same day, to the acute care hospital. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RZ0F11 Facility ID: CA240000043 If continuation sheet 9 of 13 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: _______________ 055409 (X3) DATE SURVEY COMPLETED 09/25/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COMMUNITY CARE AND REHABILITATION CENTER 4070 Jurupa Ave Riverside, CA 92506 (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 September 6, 2018, at 3:15 p.m., the Social Worker (SW) was interviewed. The SW stated every transfer to the hospital and all planned discharges are reported to the ombudsman office by e-mail and fax (facsimile) the following day. The SW stated "We keep copies of the notifications." The SW verified her signature on the Transfer/Discharge form, dated August 23, 2018. The SW was unable to find documented evidence (copy of e-mail or transmittal), the ombudsman office was notified of Resident 1's transfer.

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 10/25/2018 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RZ0F11 Facility ID: CA240000043 If continuation sheet 10 of 13 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: _______________ 055409 (X3) DATE SURVEY COMPLETED 09/25/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COMMUNITY CARE AND REHABILITATION CENTER 4070 Jurupa Ave Riverside, CA 92506 (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 findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to develop and implement a comprehensive care plan for Resident 1's cognition and increasing level of confusion. This failure potentially contributed to inadequate monitoring of Resident 1 and a subsequent fall with injury and re-admission to the acute care hospital. Findings: On September 6, 2018, an unannounced visit was made to the facility for the investigation of one complaint with multiple allegations. The record for Resident 1 was reviewed. Resident 1 was admitted to the facility from the acute care hospital, on August 16, 2018, for rehabilitation. Resident 1 was admitted with diagnoses that included cerebral hemorrhage, difficulty in walking, muscle weakness, and confusion. The Medication Administration Record (MAR) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RZ0F11 Facility ID: CA240000043 If continuation sheet 11 of 13 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: _______________ 055409 (X3) DATE SURVEY COMPLETED 09/25/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COMMUNITY CARE AND REHABILITATION CENTER 4070 Jurupa Ave Riverside, CA 92506 (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 for the month of August 2018, was reviewed and indicated Resident 1 was taking Seroquel 25 milligrams by mouth daily at bedtime for acute psychotic disorder manifested by continuous calling out. The MAR indicated a side effect of Seroquel was cognitive impairment of increased confusion. This side effect was monitored and was documented 18 times in three days (August 17-19, 2018). The Resident Admission Assessment document, dated August 16, 2018 at 5 p.m., was reviewed and the admitting nurse documented Resident 1 was admitted, to Room 305 A, in a confused state. The Nurses Notes dated August 17 through 23, 2018, were reviewed. There were multiple entries documenting Residents 1's behavior as confused, inappropriate, and needing continuous re-direction. The Resident Care Plan (CP) titled "At Risk for Falls/Injuries R/T (related to)," dated August 17, 2018, was reviewed. The CP indicated Resident 1 was at risk for falls due to poor balance, poor safety awareness, impaired decision making, medications x three with side effects of confusion, and elevated ammonia levels causing increasing confusion. The Physician's History and Physical, dated August 18, 2018, was reviewed and the symptom of confusion was documented three times. The Laboratory Report, dated August 19, 2018, was reviewed. The report indicated a high ammonia level of 99 umol/L (unit of measure). The normal range for ammonia is 16-53 umol/L. A symptom of an elevated ammonia level is confusion. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RZ0F11 Facility ID: CA240000043 If continuation sheet 12 of 13 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: _______________ 055409 (X3) DATE SURVEY COMPLETED 09/25/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COMMUNITY CARE AND REHABILITATION CENTER 4070 Jurupa Ave Riverside, CA 92506 (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 Physician's Progress Note, dated August 20, 2018, was reviewed and documented confusion as number one on Resident 1's list of diagnoses. There was no CP developed and implemented for increased confusion. The document in the record titled "Cognitive Loss/Risk for increased confusion", was located in Resident 1's record and was reviewed. Resident 1's name, physician, and room number, was documented on the CP, but the CP was never completed. On August 23, 2018, Resident 1 was found on the floor of his room, complaining of severe pain to both his lower extremities and his neck and head. Resident 1 was transferred to the acute care hospital for assessment and treatment and was re-admitted (seven days after discharge for the acute care hospital). On September 6, 2018, at 2:30 p.m., the Director of Nurses (DON) was interviewed. The DON stated Resident 1 had multiple reasons for his increasing level of confusion. DON named elevated ammonia level, history of cerebral vascular accident (CVA-stroke), subdural hemorrhage and a side effect of the medication Seroquel (psychoactive medication used to treat psychotic behavior of continuously calling out). The DON stated a CP for confusion should have been developed and implemented. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RZ0F11 Facility ID: CA240000043 If continuation sheet 13 of 13