Other·September 17, 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 represents the findings of the California Department of Public Health during an abbreviated standard survey for the investigation of two linked complaints. Complaints: CA00593893 and CA00594618. Representing the California Department of Public Health: Surveyor 29337, HFEN. The inspection was limited to the specific complaints investigated and does not represent the findings of a full inspection of the facility. Three deficiencies were issued for the linked complaints numbered CA00593893 and CA00594618.

F658 SS=D Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i)

F658 09/11/2018 §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must(i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan that met professional standards of quality for Resident 1's diagnoses of proliferative diabetic retinopathy (gel like fluid fills the back of the eye resulting in clouded vision), bilateral optic atrophy (end stage damage to the optic nerve), 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: UGNJ11 Facility ID: CA240000073 If continuation sheet 1 of 7 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: _______________ 555330 (X3) DATE SURVEY COMPLETED 07/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE POSTACUTE CARE 8781 Lakeview Ave Riverside, CA 92509 (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 bilateral blindness. Resident 1's diagnosis of blindness directly affected Resident 1's ability to self navigate about the perimeter of the facility. The under developed care plan did not provide for adequate supervision which led to Resident 1 being in the parking lot on June 30, 2018, and being struck and injured by a moving vehicle. Findings: On July 13, 2018, an unannounced visit was made to the facility for the investigation of two linked anonymous complaints about a pedestrian (Resident 1) versus automobile accident in the facility parking lot. Resident 1 was alleged to have sustained injuries to his right arm. On July 13, 2018, at 1:30 p.m., the Assistant Director of Nurses (ADON) was interviewed. The ADON stated on June 30, 2018, at 3:05 p.m., Resident 1 was in his wheelchair in the parking lot and was struck on his left side by a moving car. Resident 1 slowly fell to the ground when hit by the car. Resident 1 sustained a "big long abrasion to his right arm from the gravel." Resident 1 was alert and oriented and able to tell the staff what happened. Resident 1 stated he did not hit his head and demonstrated full range of motion (ROM) of his right arm. The ADON stated Resident 1 self propelled in his wheelchair and often goes up and down the sidewalks along the perimeter of the facility. The ADON stated, "He's alert and oriented ... The parking lot is in full view of the activity patio, but no resident should be in the parking lot." Resident 1's record was reviewed. Resident 1 was admitted to the facility January 23, 2018, with diagnoses that included unspecified visual loss and type 2 diabetes mellitus (metabolic FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UGNJ11 Facility ID: CA240000073 If continuation sheet 2 of 7 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: _______________ 555330 (X3) DATE SURVEY COMPLETED 07/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE POSTACUTE CARE 8781 Lakeview Ave Riverside, CA 92509 (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 disorder with inability to control blood sugar). The Nursing Progress Notes, dated June 30, 2018, at 3:30 p.m. through July 3, 2018, at 11:27 p.m., were reviewed and indicated the accident happened to Resident 1 in the facility parking lot as the ADON had stated. The Nursing Admission Assessment dated January 23, 2018, was reviewed. The assessment indicated Resident 1 was dependent on ADL's (activities of daily living bathing, dressing, toileting, eating, etc.) and was not at risk of wandering. In addition the assessment indicated Resident 1's vision was poor with or without glasses. Resident 1's care plan titled "Impaired Visual Function r/t (resultant to) blindness," dated February 2, 2018, was reviewed and indicated a goal for the resident was to have no acute eye problems. The intervention indicated a consultation would be arranged with eye care practitioner and tell the resident where you are placing their items. Be consistent. Resident 1's care plan was not further developed to include supervision and oversight of the resident's whereabouts. The MDS (Minimum Data Set- tool for assessing residents needs and admission and periodically throughout stay), dated May 2, 2018, was reviewed. The assessment for Resident 1's cognitive function indicated a score of 11 out of a total of 15 (moderately impaired cognition). Resident 1's care plan titled "Impaired Cognitive Function," dated May 7, 2018, was reviewed and indicated a goal for the resident to remain oriented to person, place, situation, time through the review date. The intervention indicated Resident 1 would be cued, reoriented FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UGNJ11 Facility ID: CA240000073 If continuation sheet 3 of 7 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: _______________ 555330 (X3) DATE SURVEY COMPLETED 07/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE POSTACUTE CARE 8781 Lakeview Ave Riverside, CA 92509 (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 supervised as needed. The document titled "Ophthalmology Consultation," dated July 16, 2018, was reviewed. The document indicated Resident 1 was assessed for decreased vision and had diagnoses that included "Blind OU (bilateral)". On July 13, 2018, at 2:15 p.m., Resident 1 was interviewed. Resident 1 was in his manual wheelchair in the front lobby of the facility. Resident 1's right arm was bandaged. Resident 1 stated, "It's healing. I'm blind. I just see your shadow." Resident 1 demonstrated ROM of his right arm and stated there was a barbecue occurring on the activity patio the day he was struck by the car. Resident 1 stated in order to avoid the noise and crowded activity patio he was taking the long way around the building to gain access back inside. He heard the car running, but was unsure of how long it would take for it to move, so "I went for it."

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 09/11/2018 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed ensure adequate supervision for Resident 1 as he self propelled in his wheel chair about the perimeter of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UGNJ11 Facility ID: CA240000073 If continuation sheet 4 of 7 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: _______________ 555330 (X3) DATE SURVEY COMPLETED 07/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE POSTACUTE CARE 8781 Lakeview Ave Riverside, CA 92509 (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 facility. Inadequate supervision resulted in Resident 1 being struck in the facility parking lot by a moving vehicle and sustaining injury to his right arm. Findings: On July 13, 2018, an unannounced visit was made to the facility for the investigation of two linked anonymous complaints about a pedestrian (Resident 1) versus automobile accident in the facility parking lot. Resident 1 was alleged to have sustained injuries to his right arm. On July 13, 2018, at 1:30 p.m., the Assistant Director of Nurses (ADON) was interviewed. The ADON stated on June 30, 2018, at 3:05 p.m., Resident 1 was in his wheelchair in the parking lot and was struck on his left side by a moving car. Resident 1 slowly fell to the ground when hit by the car. Resident 1 sustained a "big long abrasion to his right arm from the gravel." Resident 1 was alert and oriented and able to the staff what happened. Resident 1 stated he did not hit his head and demonstrated full range of motion (ROM) of his right arm. The ADON stated Resident 1 self propelled in his wheelchair and often goes up and down the sidewalks along the perimeter of the facility. The ADON stated, "He's alert and oriented ... The parking lot is in full view of the activity patio, but no resident should be in the parking lot." Resident 1's record was reviewed. Resident 1 was admitted to the facility January 23, 2018, with diagnoses that included unspecified visual loss and type 2 diabetes mellitus (metabolic disorder with inability to control blood sugar). The Nursing Progress Notes, dated June 30, 2018, at 3:30 p.m. through July 3, 2018, at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UGNJ11 Facility ID: CA240000073 If continuation sheet 5 of 7 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: _______________ 555330 (X3) DATE SURVEY COMPLETED 07/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE POSTACUTE CARE 8781 Lakeview Ave Riverside, CA 92509 (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 11:27 p.m., were reviewed and indicated the accident happened to Resident 1 in the facility parking lot as the ADON had stated. The Nursing Admission Assessment dated January 23, 2018, was reviewed. The assessment indicated Resident 1 was dependent on ADL's (activities of daily living bathing, dressing, toileting, eating, etc.) and was not at risk of wandering. In addition the assessment indicated Resident 1's vision was poor with or without glasses. Resident 1's care plan titled "Impaired Visual Function r/t blindness," dated February 5, 2018, was reviewed and indicated the goal was for the resident to have no acute eye problems through the review date. The interventions were to arrange consultation with eye care practitioner as required and tell the resident where you are placing their items Be consistent. Resident 1's care plan was not further developed to include supervision and oversight of the resident's whereabouts. The MDS (Minimum Data Set- tool for assessing residents needs and admission and periodically throughout stay), dated May 2, 2018, was reviewed. The assessment for Resident 1's cognitive function indicated a score of 11 out of a total of 15 (moderately impaired cognition). Resident 1's care plan titled "Impaired Cognitive Function," dated May 7, 2018, was reviewed and indicated a goal for the resident was to remain oriented to person, place, situation, time through the review date. The intervention indicated Resident 1 would be cued, reoriented and supervised as needed. The document titled "Ophthalmology Consultation," dated July 16, 2018, was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UGNJ11 Facility ID: CA240000073 If continuation sheet 6 of 7 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: _______________ 555330 (X3) DATE SURVEY COMPLETED 07/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE POSTACUTE CARE 8781 Lakeview Ave Riverside, CA 92509 (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 reviewed. The document indicated Resident 1 was assessed for decreased vision and had diagnoses that included "Blind OU (bilateral)". On July 13, 2018, at 2:15 p.m., Resident 1 was interviewed. Resident 1 was in his manual wheelchair in the front lobby of the facility. Resident 1's right arm was bandaged. Resident 1 stated, "It's healing. I'm blind. I just see your shadow." Resident 1 demonstrated ROM of his right arm and stated there was a barbecue occurring on the activity patio the day he was struck by the car. Resident 1 stated in order to avoid the noise and crowded activity patio he was taking the long way around the building to gain access back inside. He heard the car running, but was unsure of how long it would take for it to move, so "I went for it." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UGNJ11 Facility ID: CA240000073 If continuation sheet 7 of 7