Other·August 8, 2019

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 represents the findings of the California Department of Public Health during an abbreviated standard survey for the investigation of one complaint. Complaint number: CA00637228. 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 CA00637228.

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

F623 08/08/2019 §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) 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: RSJ311 Facility ID: CA240000043 If continuation sheet 1 of 19 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 07/08/2019 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 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 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RSJ311 Facility ID: CA240000043 If continuation sheet 2 of 19 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 07/08/2019 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 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 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 notify the Ombudsman office, timely, of Resident 2's pending discharge back into the community. This failure may have prevented Resident 2 from understanding his right and had a negative impact on the health and welfare of Resident 1 after discharge from FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RSJ311 Facility ID: CA240000043 If continuation sheet 3 of 19 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 07/08/2019 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 facility. Findings: On June 17, 2019, an unannounced visit was made to the facility for the investigation of one complaint. Resident 2's record was reviewed. Resident 2 was admitted to the facility in March 6, 2018, with diagnoses that included pneumonia and respiratory failure. The physician's discharge order dated May 1, 2019, was reviewed and indicated Resident 2 could be discharged home with home health care. The "Notice of Proposed Transfer/Discharge" was reviewed. The document indicated Resident 2 was notified of the impending discharge on April 29, 2019, and effective May 3, 2019. The reason for the discharge was identified as the resident's health had improved sufficiently so that the resident no longer required the services provided by the facility. The document was signed and dated by a facility representative and the Resident 2 on May 3, 2019. The confirmation of the notification to the ombudsman of the pending discharge was reviewed and indicated the ombudsman was notified on May 6, 2019, three days after Resident 1 had left the facility. On June 17, 2019, at 9:10 a.m., the facility Social Worker (SW) stated it was the nurse taking care of the resident's responsibility to prepare the "Notice of Proposed Transfer/Discharge" and notifies the resident and/or responsible party. The following day, after notification and signing, the the SW checks to see if nursing sent a copy or faxed notification to the ombudsman. If the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RSJ311 Facility ID: CA240000043 If continuation sheet 4 of 19 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 07/08/2019 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 ombudsman was not notified, the SW sends the notification. The SW stated, " I know better now, after the in-service, that it (notification) needs to be done as soon as the discharge order is written." On June 17, 2019, at 9:15 a.m., the Facility Administrator (FA) was interviewed. The FA stated the Case Manager (CM) was the back up for all notifications to the ombudsman. On June 17, 2019, at 9:30 a.m., the CM was interviewed. The CM stated, "Typically, I notify the ombudsman for all residents with HMO's (Health Maintenance Organizations - type of insurance). I don't want to assume it's been done. I sent the ombudsman notification when the discharge is certain and agreed upon by the MD (Medical Doctor), insurance, and resident." The CM did not have evidence of ombudsman notification for Resident 2.

F624 SS=D Preparation for Safe/Orderly Transfer/Dschrg CFR(s): 483.15(c)(7)

F624 08/08/2019 §483.15(c)(7) Orientation for transfer or discharge. A facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure one resident (Resident 1) was provided adequate preparation for discharge and appropriate discharge into the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RSJ311 Facility ID: CA240000043 If continuation sheet 5 of 19 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 07/08/2019 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 community to a safe lower level of care. This failure compromised Resident 1's health and resulted in re-admission to the acute care hospital. Findings: On May 16, 2019, an unannounced visit was made to the facility for the investigation of one complaint. Resident 1's record was reviewed. Resident 1 was admitted to the facility in December of 2018 with diagnoses that included Type 2 diabetes mellitus (inability to control blood sugar levels) with long term use of injectable insulin and weakness with difficulty walking. The Social Worker Progress Notes, dated January 15, 2019, were reviewed and indicated Resident 1 was being followed by a social worker, name omitted, at the local Regional Center. The social worker was working on placement in an appropriate facility with 24 hour licensed nurse coverage for assistance with medication management once Resident 1's blood sugars were stable. The Physician's Progress Notes, misdated, "5/30/19" (April 30, 2019), were reviewed. The document indicated, "... AP (action and plan)... 3. D/C (discharge) planning to Board and Care ..." The Notice of Proposed Transfer/Discharge document was reviewed. The document indicated Resident 1 was notified on May 2, 2019, of transfer to a board and care facility effective May 3, 2019. The resident's mother was also notified. The document was signed and dated by the facility social worker and the caregiver that picked Resident 1 up from the accepting facility on the day of discharge on May 3, 2019. The reason documented for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RSJ311 Facility ID: CA240000043 If continuation sheet 6 of 19 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 07/08/2019 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 discharge from the facility was, "...The transfer or discharge is appropriate because your health has improved sufficiently so that you no longer require services provided by this facility ..." The Social Service Progress Notes dated May 2, 2019, were reviewed and indicated, "... Res. was evaluated by several B & C's (Board and Care). Resident opted to go with (name omitted). Res. mother made aware and in agreement..." The Post Discharge Plan of Care dated May 3, 2019, was reviewed and indicated Resident 1 was discharged to" B & C". The B & C was crossed out and changed to "Room & Board". The Nurses Notes dated May 3, 2019, at 6:30 p.m., were reviewed and indicated the caregiver, " from the "Board & Care" came, signed all discharged paperwork ... all meds given & educated regarding med ... given all belongings..." The Medication Administration Records for the months of April and May 2019, were reviewed. Out of a total of 122 blood sugar readings, Resident 1's blood sugar was between 400 and 500 - 50 times, between 300 and 400 - 23 times, and between 200 and 300 - 17 times. Resident 1 received injectable insulin at varying amounts when her blood sugar was greater than 151. The normal blood sugar range is between 70 and 110. Additionally, five times in the month of April 2019, the Nurses Notes indicated, Resident 1 experienced signs and symptoms of low blood sugar that needed nursing interventions (April 9 at 12:30 p.m., 24 mg/dl, April 12 at 12 noon, 57 mg/dl, April 28 at 9 a.m., 27 mg/dl, April 29 at 11:30 a.m., unable to read exact number and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RSJ311 Facility ID: CA240000043 If continuation sheet 7 of 19 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 07/08/2019 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 April 30 at 2:55 p.m., 46 mg/dl). On May 16, 2019, at 3:15 p.m., the Social Worker (SW) was interviewed. The SW stated, "We thought it was a board and care. They said they could manage her (Resident 1's) blood sugars. We, (SW and two others in the office at the time) were told they (name omitted) were a board and care..." The SW stated (name omitted) was not on the list they have for board and cares, but was referred to them by another facility. The SW was unable to remember the source of the referral. On May 28, 2019, at 10:15, the Transitional Coordinator (TC) from Resident 1's insurance company was interviewed. The TC stated she had visited Resident 1 at the facility on April 16, 2019, and discussed a discharge plan for when she was ready to be discharged. The TC visited Resident 1 on May 10, 2019, (seven days after discharge) and found Resident 1 lying in urine in her bed at a room and board home with no care available. The house manager told the TC she was "frustrated and scared" because Resident 1's "... blood sugars had been out of control for many days, between 400 and 500. She was refusing food due to nausea, only had two Glucernas (liquid nutritional supplement) and was incontinent." The house manager did not know what to do. The TC called 911 and Resident 1 was transported to an acute care hospital. On June 12, 2019, at 10 a.m., the Facility Administrator (FA) was interviewed. The FA was asked how did the facility ensure a resident was discharged to the correct level of care required when leaving the facility. The FA stated "We don't have a way to do that. Is there a way? I didn't even know we had to do that." The FA stated referrals come to them in may ways and from many places. The FA further FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RSJ311 Facility ID: CA240000043 If continuation sheet 8 of 19 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 07/08/2019 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 stated, "... she (Resident 1) was discharged for her safety and the safety of others in the facility was at risk due to the lighting of matches or lighters in the bathroom ..."

F745 SS=D Provision of Medically Related Social Service CFR(s): 483.40(d)

F745 08/08/2019 §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 failed to safely discharge Resident 1 from the facility to an appropriate lower level of care into the community. This failure compromised Resident 1's health and resulted in re-admission to the acute care hospital. Findings: On May 16, 2019, an unannounced visit was made to the facility for the investigation of one complaint. Resident 1's record was reviewed. Resident 1 was admitted to the facility in December of 2018 with diagnoses that included Type 2 diabetes mellitus (inability to control blood sugar levels) with long term use of injectable insulin and weakness with difficulty walking. The Social Worker Progress Notes, dated January 15, 2019, were reviewed and indicated Resident 1 was being followed by a social worker, name omitted, at the local Regional Center. The social worker was working on placement in an appropriate facility with 24 hour licensed nurse coverage for assistance with medication management once Resident 1's blood sugars were stable. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RSJ311 Facility ID: CA240000043 If continuation sheet 9 of 19 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 07/08/2019 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 Notes, misdated, "5/30/19" (April 30, 2019), were reviewed. The document indicated, "... AP (action and plan)... 3. D/C (discharge) planning to Board and Care ..." The Notice of Proposed Transfer/Discharge document was reviewed. The document indicated Resident 1 was notified on May 2, 2019, of transfer to a board and care facility effective May 3, 2019. The resident's mother was also notified. The document was signed and dated by the facility social worker and the caregiver that picked Resident 1 up from the accepting facility on the day of discharge on May 3, 2019. The reason documented for discharge from the facility was, "...The transfer or discharge is appropriate because your health has improved sufficiently so that you no longer require services provided by this facility ..." The Social Service Progress Notes dated May 2, 2019, were reviewed and indicated, "... Res. was evaluated by several B & C's (Board and Care). Resident opted to go with (name omitted). Res. mother made aware and in agreement..." The Post Discharge Plan of Care dated May 3, 2019, was reviewed and indicated Resident 1 was discharged to" B & C". The B & C was crossed out and changed to "Room & Board". The Nurses Notes dated May 3, 2019, at 6:30 p.m., were reviewed and indicated the caregiver, " from the "Board & Care" came, signed all discharged paperwork ... all meds given & educated regarding med ... given all belongings..." The Medication Administration Records for the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RSJ311 Facility ID: CA240000043 If continuation sheet 10 of 19 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 07/08/2019 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 months of April and May 2019, were reviewed. Out of a total of 122 blood sugar readings, Resident 1's blood sugar was between 400 and 500 - 50 times, between 300 and 400 - 23 times, and between 200 and 300 - 17 times. Resident 1 received injectable insulin at varying amounts when her blood sugar was greater than 151. The normal blood sugar range is between 70 and 110. Additionally, five times in the month of April 2019, the Nurses Notes indicated, Resident 1 experienced signs and symptoms of low blood sugar that needed nursing interventions (April 9 at 12:30 p.m., 24 mg/dl, April 12 at 12 noon, 57 mg/dl, April 28 at 9 a.m., 27 mg/dl, April 29 at 11:30 a.m., unable to read exact number and April 30 at 2:55 p.m., 46 mg/dl). Resident 1's blood sugar level was not in good control. On May 16, 2019, at 3:15 p.m., the Social Worker (SW) was interviewed. The SW stated, "We thought it was a board and care. They said they could manage her (Resident 1's) blood sugars. We, (SW and two others in the office at the time) were told they (name omitted) were a board and care..." The SW stated (name omitted) was not on the list they have for board and cares, but was referred to them by another facility. The SW was unable to remember the source of the referral. On May 28, 2019, at 10:15, the Transitional Coordinator (TC) from Resident 1's insurance company was interviewed. The TC stated she had visited Resident 1 at the facility on April 16, 2019, and discussed a discharge plan for when she was ready to be discharged. The TC visited Resident 1 on May 10, 2019, (seven days after discharge) and found Resident 1 lying in urine in her bed at a room and board FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RSJ311 Facility ID: CA240000043 If continuation sheet 11 of 19 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 07/08/2019 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 home with no care available. The house manager told the TC she was "frustrated and scared" because Resident 1's "... blood sugars had been out of control for many days, between 400 and 500. She was refusing food due to nausea, only had two Glucernas (liquid nutritional supplement) and was incontinent." The house manager did not know what to do. The TC called 911 and Resident 1 was transported to an acute care hospital. On June 12, 2019, at 10 a.m., the Facility Administrator (FA) was interviewed. The FA was asked how did the facility ensure a resident was discharged to the correct level of care required when leaving the facility. The FA stated "We don't have a way to do that. Is there a way? I didn't even know we had to do that." The FA stated referrals come to them in may ways and from many places. The FA further stated, "... she (Resident 1) was discharged for her safety and the safety of others in the facility was at risk due to the lighting of matches or lighters in the bathroom ..."

F837 SS=D Governing Body CFR(s): 483.70(d)(1)(2)

F837 08/08/2019 §483.70(d) Governing body. §483.70(d)(1) The facility must have a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility; and §483.70(d)(2) The governing body appoints the administrator who is(i) Licensed by the State, where licensing is required; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RSJ311 Facility ID: CA240000043 If continuation sheet 12 of 19 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 07/08/2019 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 (ii) Responsible for management of the facility; and (iii) Reports to and is accountable to the governing body. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed: 1. to ensure a policy and procedure was developed and implemented for the process of notifying the local ombudsman for three of three sampled residents (Residents 1, 2, and 3) and 2. to ensure residents were discharged to a facility where one resident (Resident 1) had appropriate care when the resident was discharged to a room and board instead of a Board and Care as ordered by the physician. These failures had the potential for residents to not be provided added protection from being inappropriately discharged, provided with access to an advocate who could inform them of their options and rights, and ensured that the Office of the State LTC (long term care) Ombudsman was aware of facility practices and activities related to transfers and discharges. Findings: On May 16 and again on June 17, 2019, unannounced visits were made to the facility for the investigation of one complaint. 1. a. The record for Resident 1 was reviewed. Resident 1 was admitted to the facility in December of 2018 with diagnoses that included Type 2 diabetes mellitus (inability to control blood sugar levels) with long term use of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RSJ311 Facility ID: CA240000043 If continuation sheet 13 of 19 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 07/08/2019 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 injectable insulin and weakness with difficulty walking. The physician's discharge order dated May 2, 2019, was reviewed and indicated Resident 1 could be discharged back to the community with home health services on May 3, 2019. The "Notice of Proposed Transfer/Discharge" was reviewed. The document indicated Resident 1's responsible party was notified of the impending discharge on May 2, 2019, and was effective May 3, 2019. The reason for the discharge was identified as the resident's health had improved sufficiently so that the resident no longer required the services provided by the facility. The document was signed and dated by a facility representative and the caregiver that picked Resident 1 up from the facility on May 3, 2019. The confirmation of the notification to the ombudsman of the pending discharge, provided by the Social Worker (SW), was reviewed and indicated the ombudsman's office was notified on May 6, 2019, three days after Resident 1 had left the facility. On May 16, 2019, at 3:25 p.m., the facility SW was interviewed. The SW stated it was the nurse taking care of the patient' responsibility, to complete the "Notice of Proposed Transfer/Discharge", and to notify the patient and/or responsible party. The SW stated the following day, after notification and signing, the SW checks to see if nursing sent a copy or faxed notification to the ombudsman. If the ombudsman was not notified, the SW sends the notification. The SW was asked the purpose of notifying the ombudsman and the SW stated, "so that the ombudsman knows where the resident went." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RSJ311 Facility ID: CA240000043 If continuation sheet 14 of 19 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 07/08/2019 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 June 17, 2019, a return visit was made to the facility to complete the investigation. 1. b.The record for Resident 2 was reviewed. Resident 2 was admitted to the facility in March of 2018, with diagnoses that included pneumonia and respiratory failure. The physician's discharge order dated May 1, 2019, was reviewed and indicated Resident 2 could be discharged home with home health care. The "Notice of Proposed Transfer/Discharge" was reviewed. The document indicated Resident 2 was notified of the impending discharge on April 29, 2019, and effective May 3, 2019. The reason for the discharge was identified as the resident's health had improved sufficiently so that the resident no longer required the services provided by the facility. The document was signed and dated by a facility representative and the Resident 2 on May 3, 2019. The confirmation of the notification to the ombudsman of the pending discharge, provided by the SW, was reviewed and indicated the ombudsman was notified on May 6, 2019, seven days after Resident 2 was notified of the pending discharge and three days after Resident 2 had left the facility. 1. c. The record for Resident 3 was reviewed. Resident 3 was admitted to the facility April 17, 2019, with diagnoses that included fracture (break) of the left femur (large leg bone) . The physician's discharge order dated May 1, 2019, was reviewed and indicated Resident 3 could be discharged home with home health care on May 3, 2019. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RSJ311 Facility ID: CA240000043 If continuation sheet 15 of 19 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 07/08/2019 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 "Notice of Proposed Transfer/Discharge" was reviewed. The document indicated Resident 3 was notified of the impending discharge on May 1, 2019, and effective May 3, 2019. The reason for the discharge was identified as the resident's health had improved sufficiently so that the resident no longer required the services provided by the facility. The document was signed and dated by a facility representative and the Resident 3 on May 3, 2019. The confirmation of the notification to the ombudsman of the pending discharge, provided by the SW, was reviewed and indicated the ombudsman was notified on May 6, 2019, three days after Resident 3 had left the facility. On June 17, 2019, at 9:15 a.m., the Facility Administrator (FA) was interviewed. The FA stated the Case Manager (CM) was the back up for all notifications to the ombudsman. On June 17, 2019, at 9:30 a.m., the CM was interviewed. The CM stated, "Typically, I notify the ombudsman for all residents with HMO's (Health Maintenance Organizations - type of insurance). I don't want to assume it's been done. I send the ombudsman notification when the discharge is certain and agreed upon by the MD (Medical Doctor), insurance, and resident." The CM provided documentation the ombudsman was contacted timely for Residents 1 and 3, May 3 and May 2, 2019, respectively. The CM did not have evidence of ombudsman notification for Resident 2. On June 17, 2019, at 9:45 a.m., the FA was further interviewed and stated it was the facility's practice to notify the ombudsman of a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RSJ311 Facility ID: CA240000043 If continuation sheet 16 of 19 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 07/08/2019 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 pending discharge as soon as one knows where the resident is going. The FA was unsure of who was to notify the ombudsman, but thought it was the nurse. The FA stated the facility did not have a written policy and procedure for the process and the Facility Operations Manual referred her to an AFL (All Facilities Letter) dated December 15, 2016. 2. On May 16, 2019, an unannounced visit was made to the facility for the investigation of one complaint. Resident 1's record was reviewed. Resident 1 was admitted to the facility in December of 2018 with diagnoses that included Type 2 diabetes mellitus (inability to control blood sugar levels) with long term use of injectable insulin and weakness with difficulty walking. Further review of Resident 1's record located facility Social Worker Progress Notes, dated January 15, 2019, that indicated Resident 1 was being followed by a social worker, name omitted, at the local Regional Center (RC). The (RC) social worker was working on placement in an appropriate facility with 24 hour licensed nurse coverage for assistance with medication management once Resident 1's blood sugars were stable. The Physician's Progress Notes, misdated, "5/30/19" (April 30, 2019), were reviewed. The document indicated, "... AP (action and plan)... 3. D/C (discharge) planning to Board and Care ..." The Social Service Progress Notes dated May 2, 2019, were reviewed and indicated, "... Res. was evaluated by several B & C's (Board and Care). Resident opted to go with (name omitted). Res. mother made aware and in agreement..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RSJ311 Facility ID: CA240000043 If continuation sheet 17 of 19 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 07/08/2019 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 Post Discharge Plan of Care dated May 3, 2019, was reviewed and indicated Resident 1 was discharged to" B & C". The B & C was crossed out and changed to "Room & Board". The Nurses Notes dated May 3, 2019, at 6:30 p.m., were reviewed and indicated the caregiver, " from the "Board & Care" came, signed all discharged paperwork ... all meds given & educated regarding med ... given all belongings..." On May 16, 2019, at 3:15 p.m., the facility Social Worker (SW) was interviewed. The SW stated, "We thought it was a board and care. They said they could manage her (Resident 1's) blood sugars. We, (SW and two others in the office at the time) were told they (name of room and board omitted) were a board and care..." The SW stated (name of room and board omitted) was not on the list they have for board and cares, but was referred to them by another facility. The SW was unable to remember the source of the referral. On May 28, 2019, at 10:15, the Transitional Coordinator (TC) from Resident 1's insurance company was interviewed. The TC stated she had visited Resident 1 at the facility on April 16, 2019, and discussed a discharge plan for when she was ready to be discharged. The TC visited Resident 1 on May 10, 2019, (seven days after discharge) and found Resident 1 lying in urine in her bed at a room and board home with no care available. The house manager told the TC she was "frustrated and scared" because Resident 1's "... blood sugars had been out of control for many days, between 400 and 500. She was refusing food due to nausea, only had two Glucernas (liquid nutritional supplement) and was incontinent." The house manager did not know what to do. The TC called 911 and Resident 1 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RSJ311 Facility ID: CA240000043 If continuation sheet 18 of 19 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 07/08/2019 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 transported to an acute care hospital. On June 12, 2019, at 10 a.m., the Facility Administrator (FA) was interviewed. The FA was asked how did the facility ensure a resident was discharged to the correct level of care required when leaving the facility. The FA stated "We don't have a way to do that. Is there a way? I didn't even know we had to do that." The FA stated referrals come to them in may ways and from many places. The FA further stated, "... she (Resident 1) was discharged for her safety and the safety of others in the facility was at risk due to the lighting of matches or lighters in the bathroom ..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RSJ311 Facility ID: CA240000043 If continuation sheet 19 of 19