Other·May 11, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a Recertification Survey conducted April 2, 2018 to April 5, 2018. Representing the California Department of Public Health: Surveyor 36684, HFEN; Surveyor 25281, Pharmacist Consultant II; Surveyor 29623, HFEN, Surveyor 37548, HFEN; and Surveyor 38479, HFEN. The facility census was 65 residents. The sample size was 27 residents. The following were included during the survey: One deficiency was issued for Facility Reported Incidents CA00565398 (initiated December 20, 2017), CA00567260 (initiated December 29, 2017), linked with Complaint CA00566952 (initiated December 29, 2017). Refer to F600; No deficiency was issued for Complaints CA00581235 and CA00579737; and No deficiency was issued for Facility Reported Incident CA00580378.

F578 SS=E Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir CFR(s): 483.10(c)(6)(8)(g)(12)(i)-(v)

F578 05/17/2018 §483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental 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: 3H3Z11 Facility ID: CA240000081 If continuation sheet 1 of 44 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: _______________ 555884 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr 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 research, and to formulate an advance directive. §483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate. §483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. (ii) This includes a written description of the facility's policies to implement advance directives and applicable State law. (iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. (iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law. (v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed, for eight of 27 sampled residents FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z11 Facility ID: CA240000081 If continuation sheet 2 of 44 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: _______________ 555884 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr 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 (Residents 58, 63, 51, 55, 32, 64, 217, and 221), to ensure an advance directive (written instruction such as living will or durable power of attorney for health care about the provision of care and services the resident preferred when he is no longer able to decide for himself) was initated and/or discussed with the resident, family member, and/or legal representatative upon admission to the facility. This failure had the potential for the residents to have inappropriate treatment and services in the event of a medical emergency. Findings: 1. On April 3, 2018, Resident 55's record was reviewed. Resident 55 was re-admitted to the facility on March 28, 2018, with diagnoses that included schizophrenia (mental disorder). The completed Physician's Orders for LifeSustaining Treatment (POLST- form completed by the resident and/or legal representive, that records the resident's treatment preferences in the event of a medical emergency), dated November 19, 2017, did not indicate if an advance directive was initiated and/or discussed with the resident's legal representative. On April 3, 2018, at 10:23 a.m., the Social Service Designee (SSD) was interviewed. The SSD stated she was unable to find documented evidence an advance directive was initiated and/or discussed with the resident's legal representative.The SSD stated she should have discussed and documented that an advance directive was initiated and/or discussed with Resident 55's legal representative. 2. On April 3, 2018, Resident 63's record was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z11 Facility ID: CA240000081 If continuation sheet 3 of 44 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: _______________ 555884 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr 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. Resident 63 was re-admitted to the facility on March 12, 2018, with a diagnoses that included dementia (memory loss). There was no documented evidence an advance directive was initiated and/or discussed with the resident and/or legal representative. On April 3, 2018, at 10:30 a.m., the SSD was interviewed. The SSD stated she was unable to find documented evidence of an advance directive in Resident 63's record. The SSD stated she should have discussed and documented Resident 63's advance directive with Resident 63's legal representative upon admission. 3. On April 3, 2018, Resident 58's record was reviewed. Resident 58 was admitted to the facility on October 30, 2017, with diagnoses that included dementia. The completed POLST, dated November 6, 2018, did not indicate if an advance directive was initiated and/or discussed with the resident and/or legal representative. 4. On April 3, 2018, Resident 51's record was reviewed. Resident 51 was re-admitted to the facility on December 19, 2017, with diagnoses that included dementia. The completed POLST, dated August 3, 2017, did not indicate if an advance directive was initiated and/or discussed with the resident's legal representative. 5. On April 2, 2018, Resident 32's record was reviewed. Resident 32 was admitted to the facility on July 6, 2017, with diagnoses that included dementia. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z11 Facility ID: CA240000081 If continuation sheet 4 of 44 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: _______________ 555884 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr 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 The completed POLST, dated September 11, 2017, did not indicate if an advance directive was initiated and/or discussed with the resident's legal representative. On April 3, 2018, at 1:30 p.m., the Social Service Designee (SSD) was interviewed. The SSD stated there was no documented evidence in Residents 51, 58, and 32's record that an advance directive was initiated and discussed with the resident's legal representative. The SSD further stated Resident 32's advance directive should have been initiated and/ or discussed with the resident's legal representative upon admission to the facility. 6. On April 2, 2018, at 9:36 a.m., Resident 64 was observed lying supine (flat on one's back, face upward) in his bed. The resident was awake and was not able to answer simple questions. On April 4, 2018, Resident 64's record was reviewed. Resident 64 was admitted to the facility on February 28, 2018, with diagnoses including dementia and seizure disorder (an abnormal disruption of brain activity causing convulsions). The resident's "History And Physical" dated March 6, 2018, completed by the physician indicated the resident "has fluctuating capacity to understand and make decisions." Resident 64's POLST, dated March 6, 2018, was reviewed. The POLST indicated the resident had no advance directive. There was no documented evidence the facility had discussed the advance directive to the resident or his legal representative. There was no documented evidence the facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z11 Facility ID: CA240000081 If continuation sheet 5 of 44 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: _______________ 555884 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr 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 had provided assistance to initiate the formulation of the resident's advance directive. On April 4, 2018, at 2:22 p.m., a concurrent interview and record review was conducted with the SSD. The SSD stated she did not know the resident had no advance directive. She also acknowledged she did not discuss and assist Resident 64 in the formulation of the resident's advance directive. 7. On April 4, 2018, Resident 217's record was reviewed. Resident 217 was admitted to the facility on February 28, 2018, with diagnoses including cerebrovascular accident (CVA stroke). The resident's "History And Physical," signed and dated on March 2, 2018, by Resident 217's physician indicated, "...has the capacity to understand and make decisions..." The resident's POLST was reviewed. The "Information And Signatures" sections related to the advance directive and the physician's signature were blank. There was no documented evidence in the resident's record the advance directive was discussed with the resident and the POLST was signed by the physician. On April 4, 2018, at 9:52 a.m., a concurrent interview and record review was conducted with the SSD. The SSD stated she was not aware the resident's POLST was not signed by the physician and the advance directive was not filled out. The SSD further stated she was responsible to follow up on resident's advance directive and made sure the POLST was completed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z11 Facility ID: CA240000081 If continuation sheet 6 of 44 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: _______________ 555884 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr 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 8. On April 4, 2018, Resident 221's record was reviewed. Resident 221 was admitted to the facility on March 9, 2018, with diagnoses including chronic obstructive pulmonary disease (COPD - a lung disease). The resident's POLST, dated and signed by the resident's physician on March 10, 2018, was reviewed. The document indicated the advance directive was blank. There was no documented evidence the advance directive for Resident 221 was initiated and discussed with the resident. On April 4, 2018, at 10:17 a.m., a concurrent record review and interview was conducted with SSD. The SSD stated she was not aware the resident's advance directive was blank. She stated she did not initiate or discussed the advance directive with Resident 221. On April 4, 2018, the facility's policy and procedure titled, "Advance Directive," dated April 2013, was reviewed. The policy indicated, "...Upon admission of a resident, the Social Services Director or designee will inquire of the resident, and /or his/her family members, about the existence of any written advance directive...Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record...The attending physician will provide information to the resident and legal representative regarding the resident's health status, treatment options and expected outcomes during the development of the initial comprehensive assessment and care plan..."

F600 SS=G Free from Abuse and Neglect CFR(s): 483.12(a)(1)

F600 05/17/2018 §483.12 Freedom from Abuse, Neglect, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z11 Facility ID: CA240000081 If continuation sheet 7 of 44 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: _______________ 555884 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr 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 Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to: 1. Ensure Resident A was free from sexual abuse, when Resident A was left in the dining room on December 18, 2017, without staff supervision with other residents, including Resident B, who had a known behavior of sexual inappropriateness; and 2. Ensure Resident A does not experience another sexual abuse, when Resident A was left in the dining room without staff supervision for the second time on December 29, 2017, with other residents, including Resident C, who had a known behavior of sexual inappropriatess. These failures resulted in Resident A to be sexually abused twice while at the facility. Findings: 1. On December 20, 2017, at 9:30 a.m., an unannounced visit was conducted to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z11 Facility ID: CA240000081 If continuation sheet 8 of 44 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: _______________ 555884 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr 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 investigate a facility reported incident related to sexual abuse. On December 20, 2017, at 10:23 a.m., Resident A was observed in the dining room sitting in a wheelchair, leaning forward, with her head resting on the table. Resident A did not wake up when her name was called. On December 20, 2017, at 10:25 a.m., the facility Administrator was interviewed. The facility Administrator stated he was informed by the Restorative Nursing Assistant (RNA) 1 on December 18, 2017, of an incident of sexual abuse involving Residents A and B. The facility Administrator stated RNA 1 had witnessed the incident. On December 20, 2017 at 1:27 p.m., RNA 1 was interviewed. RNA 1 stated on December 18, 2017, at around 10 a.m., she walked into the dining room and saw Resident B in a sitting position facing the wall and was hunched over Resident A. RNA 1 saw Resident A's shirt was pulled up over her breasts and Resident B's left hand was squeezing the right breast of Resident A while his mouth was sucking on Resident A's left breast. RNA 1 also stated there were a lot of residents in the dining room at that time but did not see any staff. RNA 1 also stated she immediately separated Residents A and B and called for help. RNA 1 further stated Activity Assistant (AA) 1 came into the dining room when she called for help. On December 20, 2017, Resident A's clinical record was reviewed. Resident A was admitted to the facility on April 6, 2017, with diagnoses which included encephalopathy (altered mental state characterized by impairment of cognition, attention, orientation and consciousness), muscle weakness and difficulty in walking. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z11 Facility ID: CA240000081 If continuation sheet 9 of 44 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: _______________ 555884 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr 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 Resident A's "History and Physical," dated April 10, 2017, indicated Resident A did not have the capacity to understand and make decisions. Resident A's "Minimum Data Set" (MDS- a comprehensive assessment and care-planning tool), dated October 18, 2017, indicated Resident A had severe cognitive impairment (condition when a person has trouble remembering, learning new things, concentrating or making daily decisions affecting daily life), required limited assistance with one-person assist with ambulation, and was totally dependent on staff with eating, toileting, personal hygiene, and bathing. On December 20, 2017, Resident B's clinical record was reviewed. Resident B was admitted to the facility on May 16, 2017, with diagnoses which included diabetes mellitus (high blood sugar), hypertension (elevated blood pressure), and anxiety disorder (mood disorder). Resident B's MDS, dated November 27, 2017, indicated resident B had clear speech, made self understood, and had the ability to understand others, had moderately impaired cognition, required limited assistance with oneperson assist with ambulation, toileting, and personal hygiene, and able to move to and return from off-unit locations (including dining and activities) with supervision using a wheelchair. Resident B's care plan titled, "Impaired Behavior Status," indicated the following: a. On May 22, 2017, "...sexually inappropriate behavior m/b (manifested by) attempting to place his hand into a female resident's pants..." The goal for this problem indicated, "...will have no episode of inappropriate behavior..." The care plan was re-evaluated on August 2017 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z11 Facility ID: CA240000081 If continuation sheet 10 of 44 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: _______________ 555884 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr 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 November 2017. One of the approaches/plan included was to attempt to redirect resident; b. On June 5, 2017, "Inappropriate behavior m/b trying to touch a female resident," was documented. There were no approaches/plans developed to address this behavior; and c. On September 22, 2017, "Inappropriate behavior of touching another female resident," was documented. The approaches/plan included to monitor Resident B's behavior closely and remind resident not to go near the other resident. Resident B's nurse's notes, dated October 23, 2017, indicated Resident B was observed behind another resident in the dining room, with Resident B's hands under the resident's left sleeves, grabbing her chest. Nurse's notes further indicated Resident B was put on 72 hours monitoring for inappropriate behavior and frequent visual check. Resident B's nurse's notes, dated December 18, 2017, indicated, "At approximately 1000 am staff notified this writer of resident having a sexual inappropriate BX (behavior) in dinning (sic) area. Staff member observed male resident leaning forward a female resident, while having her shirt pulled over breasts. He was holding her R (right) breast in his mouth ...Resident (Resident B) had New order to send resident out to (name of psych hospital) for further Eval (evaluation) ..." On December 29, 2017, at 10:18 a.m., AA 1 was interviewed. AA 1 stated he was the one assigned to provide supervision in the dining room on December 18, 2017, for residents who attend activities. AA 1 stated Residents A and B were present in the dining room during the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z11 Facility ID: CA240000081 If continuation sheet 11 of 44 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: _______________ 555884 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr 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 activity. AA 1 also stated he was aware of Resident B's previous episodes of inappropriate sexual behavior towards other female residents. He stated facility staff provided closer monitoring to residents who had previous inappropriate behavior to make sure they were not too close to female residents. AA 1 also stated he stepped out of the dining room three times and went to Nursing Station 1 to remind nursing staff to pass snacks to residents. AA 1 also stated when he came back to the dining room after the third time, RNA 1 already separated Resident B from Resident A. AA 1 further stated he should not have left the dining room. On December 29, 2017, at 11:10 a.m., the facility Administrator was interviewed. The facility Administrator stated AA 1 was assigned to the dining room when the incident happened between Residents A and B. The facility Administrator also stated there should always be a staff present in the dining room when residents are present. On December 29, 2017, at 3:40 p.m., the Director of Nursing (DON) was interviewed. The DON stated, "Staff should be present in the dining area if there are residents who were identified before with behavior of sexual inappropriateness." On January 18, 2018, the (Name of county) County Sheriff's incident report dated December 18, 2017, was reviewed. The sheriff's incident report indicated, on December 18, 2017, the sheriff reviewed the surveillance video of the incident with the Administrator. The incident report indicated, "...In the surveillance video you can see several clients and two staff members in the dining room. As the staff members walked out of the dining room, you can see (Resident B's name) wheel FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z11 Facility ID: CA240000081 If continuation sheet 12 of 44 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: _______________ 555884 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr 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 himself to where Doe (an injunction used for someone whose identity was not known at the time it was issued/Resident A) was sitting." The incident report indicated Resident B leaned over onto Resident A's torso and stayed in the same position for approximately 10-15 minutes without interruption, until RNA 1 approached Resident B and separated him from Resident A. 2. On December 29, 2018, at 8:10 a.m., another visit was conducted at the facility to investigate a second incident of sexual abuse involving Resident A by another male resident (Resident C). On December 29, 2017, at 1:08 p.m., Certified Nursing Assistant (CNA) 1 was interviewed. CNA 1 stated there was an incident of sexual abuse that happened involving Residents A and C "Right before change of shift this morning." CNA 1 also stated Resident D was the witness. CNA 1 further stated Resident D was interviewable. On December 29, 2017, at 1:12 p.m., Resident A was observed up in a wheelchair in the small activity room. Resident A did not make any eye contact, and did not respond verbally when asked how she was doing. On December 29, 2017, at 1:14 p.m., CNA 2 was interviewed. CNA 2 stated when there was a resident in the TV room or dining room, a staff should always be there. On December 29, 2017, at 1:16 p.m., Resident D was interviewed with CNA 2 present. Resident D stated she was in the dining room on December 29, 2018, at around 5:30 a.m. Resident D also stated she saw Resident C sucking on Resident A's breast one at a time, with Resident C's hand touching Resident A's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z11 Facility ID: CA240000081 If continuation sheet 13 of 44 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: _______________ 555884 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr 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 crotch area and "masturbated her." Resident D also stated there was no staff present in the dining room when the incident happened. Resident D also stated she yelled, "He's (Resident C) sucking her (Resident A) tities (breast)," and "help, help." Resident D further stated Resident C ran away from Resident A when she yelled for help. On December 29, 2017, at 2:45 p.m., CNA 3 was interviewed regarding the incident involving Resident A and C. CNA 3 stated she got Resident A up in a wheelchair and to the dining room on December 29, 2018, at around 5:40 a.m. CNA 3 also stated there were about six or seven residents in the dining room, including Residents C and D. CNA 3 also stated she stepped out of the dining room and was in the hallway near Nursing Station 1 when she heard somebody yelled from the dining room. CNA 3 also stated she ran into the dining room and saw Resident C looking frightened and was walking very fast away from Resident A. CNA 3 also stated Resident D was yelling, "He's (Resident C) sucking on (Resident A's) tities." CNA 3 also stated she thought it would be safer for Resident A to stay in the dining room because there were more people in there. CNA 3 also stated she was aware of Resident C's history of inappropriate gestures of touching other female residents and she would always remind Resident C not to do it. CNA 3 also stated Resident A was an easy target because she was non-verbal and could not defend herself. CNA 3 further stated she could not recall if there was a staff present in the dining room. On December 29, 2017, at 3:11 p.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated, on December 29, 2017, at around 5:40 to 5:50 a.m., while he was inside Nursing Station 1, he heard somebody yelling FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z11 Facility ID: CA240000081 If continuation sheet 14 of 44 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: _______________ 555884 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr 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 from the dining room. LVN 1 also stated he rushed into the dining room behind CNA 3. LVN 1 also stated by the time he went into the dining room, he saw Resident D by the exit door near the front lobby. LVN 1 also stated there was no staff present in the dining room when the incident happened. LVN 1 further stated a sheriff came within 20 minutes and interviewed Resident D. On December 29, 2017, at 3:30 p.m., a followup interview was conducted with Resident D. Resident D stated, there was no staff present this morning at around 5:30 in the dining room when Resident C, "sucked" Resident A's "tities." Resident D also stated, "(Resident C's name) grabbed (Resident A's name) crotch and masturbated her." Resident D stated staff came to the dining room after she yelled for help. On December 20, 2017, Resident A's clinical record was reviewed. Resident A was admitted to the facility on April 6, 2017, with diagnoses which included encephalopathy, muscle weakness, and difficulty in walking. Resident A's "History and Physical," dated April 10, 2017, indicated Resident A did not have the capacity to understand and make decisions. Resident A's MDS, dated October 18, 2017, indicated Resident A had severe cognitive impairment, required limited assistance with one-person assist with ambulation, and was totally dependent on staff with eating, toileting, personal hygiene, and bathing. Resident A's "Departmental Notes," dated December 18, 2017, indicated, "...resident was sitting in dining room with male resident sitting facing her leaning forward...female's shirt was pulled over her breasts...male resident had his left hand on right breast as he squeezed it...he FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z11 Facility ID: CA240000081 If continuation sheet 15 of 44 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: _______________ 555884 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr 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 had his mouth on her left breast...female resident placed on 72 hour monitoring for emotional distress..." Resident A's "Short Term Care Plan", dated December 18, 2017, indicated Resident A was at risk for emotional distress due to recent events with male resident. The interventions included: - Encourage resident to participate in activities; - Report to MD (Medical Doctor) any change of condition; - Assess for pain and discomfort; and - Frequent visual check to ensure comfort. Resident A's "Psychology Consult," dated December 19, 2017, indicated, "...Patient was referred to be evaluated as a result of an incident related to inappropriate touching by a male resident towards patient...patient presented calm and mostly unresponsive...does not show any emotion...evaluated for emotional distress...patient does not seem to be aware of the incident..." On December 29, 2017, Resident C's clinical record was reviewed with the DON (Director of Nursing). Resident C was admitted to the facility on May 8, 2015. Resident C's Annual Physician Assessment, dated March 1, 2017, indicated Resident C did not have the capacity to understand and make decisions. Resident C had diagnoses including schizophrenia (a mental disorder). Resident C's "Behavior Care Plan," dated February 20, 2017, indicated, "...Problems/Needs...needs behavior management r/t (related to) touching the female residents and staff...goals...will have less episode of behavior to touch the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z11 Facility ID: CA240000081 If continuation sheet 16 of 44 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: _______________ 555884 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr 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 female...behavior will be redirected daily x (times)3 months...approaches/plan...monitor episodes of behavior every shift for inappropriateness...educated the resident to stop that behavior because this inappropriate...redirect the resident to other activities...Re-eval (Re-evaluation) dates...5/17 (May 2017)...8/17 (August 2017)...11/17 (November 2017)...2/18 (February 2018)..." Resident C's "Departmental Notes," dated February 21, 2017, indicated, "...IDT (Interdisciplinary Team) for 2/20/2017...Resident grabbed/touched a female resident's left breast then he walked away...IDT recommendation...monitor resident's behavior closely...move other resident away when he is walking in the hallway...remind staff to step away when resident walks in his way..." Resident C's "Behavior Care Plan," dated March 7, 2017, indicated, "...Problem/Needs...touching inappropriately other female resident..." There were no approaches/plans developed to address this behavior. Resident C's "Departmental Notes," dated March 8, 2017, indicated, "...IDT review for 3/07/2017...a female resident was heard screaming for assistance when this resident grabbed her hand and place it inside his pants...IDT recommends to do frequent visual check and to monitor..." Resident C's "Behavior Care Plan," dated April 16, 2017, indicated, "...Problem/Needs...touching female resident unnecessarily..." There were no approaches/plans developed to address this behavior. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z11 Facility ID: CA240000081 If continuation sheet 17 of 44 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: _______________ 555884 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr 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 Resident C's "Departmental Notes," dated April 17,2016, indicated "...IDT review for 4/16/2017...Resident was found grabbing another female resident by her hips...IDT recommends to redirect when around female residents; educate on inappropriate behavior..." Resident C's "Psychological Services Progress Notes," dated April 17, 2017, indicated, "...continued to experience difficulties with boundaries...sat with patient and talked about...inappropriate vs (versus) appropriate touching...he laughs as if he is aware he acts inappropriately, he agreed to try..." Resident C's "Psychological Services Progress Notes," dated June 7, 2017, indicated, "...continues to experience delusions (false belief) and inappropriate behavior... worked on psychoeducation about appropriate vs inappropriate touching... he listens and stops, however staff continues to report ongoing inappropriate behavior..." Resident C's "Psychological Services Progress Notes," dated June 21, 2017, indicated, "...continues to experience...difficulties interacting appropriately and inappropriate touching and gestures..." Resident C's "Psychological Services Progress Notes," dated July 3, 2017, indicated, "...continues to experience anxiety, inappropriate boundaries and inappropriate touching...engaged resident by pointing out appropriate approach..." Resident C's "Psychology Progress Notes," dated August 28, 2017, indicated, "...tends to approach people and want to touch female's buttocks and think it is funny..." Resident C's MDS dated November 17, 2017, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z11 Facility ID: CA240000081 If continuation sheet 18 of 44 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: _______________ 555884 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr 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 indicated Resident C had severe cognitive impairment, and did not require assistance with transfers and ambulation. On December 29, 2017, at 3:35 p.m., the facility Administrator was interviewed. The facility Administrator stated it was CNA 2 who got Resident A up to the dining room at around 5:40 a.m. on December 29, 2017. The facility Administrator also stated the dining room was left unsupervised for a couple of minutes. The facility Administrator also stated there should always be a staff present in the dining room when residents are present. On December 29, 2017, at 3:40 p.m., the DON was interviewed. The DON stated "Staff should be present in the dining room if there are residents who were identified before with behavior of sexual inappropriateness." The DON also stated Resident A was placed on one-on-one sitter after the second incident of sexual abuse to Resident A. The DON further stated the facility would arrange for Resident A to be transferred to another facility. On March 1, 2018, the (Name of county) County Sheriff's incident report dated December 29, 2017, was reviewed. The Sheriff's incident report indicated, "...I responded to a reported call of sexual battery...The surveillance video showed on 12/29/17, about 0540 hours, (Resident C's name) grabbing (Resident A's name) breasts and vagina...The video also showed (Resident C's name) lifting (Resident A's name) shirt to expose her breasts...(Resident C's name) then bent over and placed his mouth in the area of (Resident A's name) breasts...I placed a 5150 WIC (section of Welfare and Institutions Code authorizes a qualified officer or clinician to involuntarily confine a person suspected to have a mental disorder that makes them a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z11 Facility ID: CA240000081 If continuation sheet 19 of 44 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: _______________ 555884 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr 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 danger to themselves, a danger to others, or gravely disabled) hold on (Resident C's name) for being a danger to others and gravely disabled..." The facility policy and procedure (P/P) titled, "Abuse Prevention Program," dated August 2006, was reviewed. The P/P indicated,"... residents have the right to be free from abuse...Our abuse prevention program provides policies and procedures that govern, as a minimum...Identification of occurrences and patterns of potential mistreatment/abuse...An ongoing review and analysis of abuse incidents...The implementation of changes to prevent future occurrences of abuse."

F657 SS=D Care Plan Timing and Revision CFR(s): 483.21(b)(2)(i)-(iii)

F657 05/17/2018 §483.21(b) Comprehensive Care Plans §483.21(b)(2) A comprehensive care plan must be(i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-(A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z11 Facility ID: CA240000081 If continuation sheet 20 of 44 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: _______________ 555884 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr 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 disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to review and revise the comprehensive long term care plan when the resident's left lower leg swelling and redness had recurred, for one of 27 sampled residents (Resident 53). This failure had the potential to delay the necessary care and services needed for Resident 53's edema and identify other medical condition contributing to persistent edema. Findings: On April 2, 2018, at 11:36 a.m., Resident 53 was observed in her room sitting at the edge of the bed, taking off both socks and her slipper booties. The resident's left lower leg was observed to be swollen. Resident 53 was alert and able to verbalize her needs. A concurrent interview was conducted with the resident. She stated her left lower leg had been swollen since March 2018. She further stated she needed to put her left leg up while in bed. On April 2, 2018, at 12:14 p.m., Resident 53 was observed walking towards the dining room, wearing a raincoat and her slipper booties. On April 3, 2018, at 2:49 p.m., Resident 53 was observed in her room. The resident was sitting at the edge of her bed, taking off her left sock. The left lower leg edema was still present. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z11 Facility ID: CA240000081 If continuation sheet 21 of 44 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: _______________ 555884 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr 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 A concurrent interview was conducted with the resident. She stated her physician had increased the dose of Lasix (a medication used to reduce extra fluid in the body) to twice a day. She stated she felt the swelling was less compared to yesterday (April 2, 2018). She stated she would continue to elevate her left leg. On April 4, 2018, Resident 53's record was reviewed. Resident 53 was admitted to the facility on April 30, 2017, and readmitted on January 26, 2018, with diagnoses including hypertension (high blood pressure). The nurse's note, dated March 9, 2018, entered electronically at 10:41 p.m. by licensed staff indicated, "...Resident came to nursing station stated her left foot was hurting. Upon assessment noted left foot was swollen, pitting (observable swelling due to fluid accumulation that may be demonstrated by applying pressure to the swollen area) + 3 with blanchable (a condition when an area looses all redness when pressed) redness around ankle area, hot to touch...Keflex (an antibiotic used for infection) 500 milligram (mg) po (by mouth) four times a day (QID) x 7 days for cellulitis..." The nurse's note dated March 21, 2018, entered electronically at 1:57 p.m., by licensed staff indicated, "...resident alert and responsive able to make needs known to staff...MD (medical doctor) notified r/t (related to) left lower leg swelling, and redness..." On April 4, 2018, at 9:10 a.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 was not able to locate a care plan related to the resident's cellulitis and edema. She stated the licensed staff who identified the problem on March 9, 2018, should have initiated the care FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z11 Facility ID: CA240000081 If continuation sheet 22 of 44 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: _______________ 555884 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr 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 plan. On April 4, 2018, at 2:58 p.m., a concurrent interview and record review was conducted with LVN 2. The nursing notes dated March 9, 2018, indicated LVN 2 was the licensed staff on duty when Resident 53 verbalized her complaint of left leg edema and cellulitis. LVN 2 was able to locate an undated short term care plan related to left foot cellulitis with goal "will resolve x 7 days." LVN 2 stated she initiated the short term care plan for the resident's left foot cellulitis because of the seven days antibiotic. She stated she should have revised the short term care plan and initiated a long term care plan for Resident 53. She acknowledged the resident's edema was still present. The facility's policy and procedure titled, "Care Plans - Comprehensive," dated September 2010, was reviewed. The policy indicated, "...An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident...Assessment of residents are on going and care plans are revised as information about the resident and the resident's condition change..."

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

F658 05/17/2018 §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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z11 Facility ID: CA240000081 If continuation sheet 23 of 44 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: _______________ 555884 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr 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 by: Based on observation, interview, and record review, the facility failed to ensure, for one of 27 sampled residents (Resident 55), the physician was notified of the resident's refusal to have her blood drawn for laboratory testing. This failure had the potential for a delay in treatment and services for the resident. Findings: On April 3, 2018, at 10 a.m., Resident 55 was observed in her room, awake and conversant. Resident 55 did not have signs of agitation during the observation. On April 4, 2018, Resident 55's record was reviewed with Registered Nurse (RN) 1. Resident 55 was re-admitted to the facility on March 28, 2018, with diagnoses that included epilepsy (seizure disorder), hypothyroidism (low thyroid hormone in the blood), hyperlipidemia (high cholesterol level in the blood), and schizophrenia (mental disorder). The physician's order, dated March 28, 2018, indicated, "ROUTINE LABS...TSH (Thyroid Stimulating Hormone- blood test that measures thyroid level), VPA (Valproic Acid- blood test that measure valproic acid level), CMP (Comprehensive Metabolic Panel- blood test that measure sugar level, electrolytes, fluid balance, kidney function, and liver function), HgA1C (HemoglobinA1C- blood test that measures the average sugar level in the past three months) (MAR {March},SEPT {September}), Annual Prolactine (blood test used to measure prolactine hormone related to Zyprexa use)..." The laboratory requisition form, indicated the TSH, VPA, CMP, Lipid Panel, HGA1C, and Prolactin level, were supposed to be drawn on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z11 Facility ID: CA240000081 If continuation sheet 24 of 44 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: _______________ 555884 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr 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 March 29, 2018. The laboratory requisition form also indicated Resident 55 had refused the laboratory tests on March 29, 2018, March 30, 2018, and April 3, 2018. The laboratory requisition form also indicated the licensed nurse verified through signature that Resident 55 refused the laboratory tests on those dates. In a concurrent interview, RN 1 stated Resident 55 refused the blood draw for the laboratory orders on March 29, 2018, March 30, 2018, and April 3, 2018. RN 1 stated the licensed nurse on duty should have notified Resident 55's physician about the refusal. RN 1 stated she did not find documented evidence the licensed nurse notified Resident 55's physican when she had refused the blood draw on March 29, 2018, March 30, 2018, and April 3, 2018. On April 4, 2018, at 10:40 a.m., the Director of Nursing (DON) was interviewed. The DON stated the licensed nurse on duty should have notified the resident's physician each time the resident refused a blood draw. The DON stated the licensed nurse should have documented when the physician was notified.

F677 SS=D ADL Care Provided for Dependent Residents CFR(s): 483.24(a)(2)

F677 05/17/2018 §483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the resident's fingernails were kept clean and trimmed according to the resident's preferences for one of 27 sampled residents (Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z11 Facility ID: CA240000081 If continuation sheet 25 of 44 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: _______________ 555884 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr 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 217). This failure had the potential for the resident to accidentally injure his skin or others' and the development of infection due to unhygienic practices. Findings: On April 2, 2018, at 8:57 a.m., Resident 217 was observed lying flat in bed. Resident 217 was awake, alert, and able to answer simple questions. The resident's fingernails on both hands were long and were observed with some dry brownish materials underneath the nail beds. A concurrent interview was conducted with Resident 217. The resident was asked if he wanted to keep his nails long. He stated "No". He stated he wanted someone to "cut" his nails. On April 2, 2018, at 12:15 p.m., Resident 217 was observed in the dining room. Resident 217 was eating his lunch independently. The resident's fingernails were untrimmed and the same dry brownish materials remained underneath the nail beds. On April 2, at 12:46 p.m., Resident 217 was observed in his room. The resident's fingernails remained untrimmed and uncleaned On April 3, 2018, at 9:30 a.m., the resident was observed awake, lying in his bed. The resident's fingernails remained untrimmed and still with dry brownish materials underneath the nail beds. On April 3, 2018, at 9:35 a.m., Licensed Vocational Nurse (LVN) 3 was requested to check the resident's fingernails. Resident 217's permission was requested if he could show LVN 3 his fingernails. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z11 Facility ID: CA240000081 If continuation sheet 26 of 44 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: _______________ 555884 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr 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 Resident 217 raised his both hands and stated "I want them cut." LVN 3 stated the direct care staff should have cleaned and trimmed the resident's fingernails. On April 4, 2018, Resident 217's record was reviewed. Resident 217 was admitted to the facility on February 28, 2018, with diagnoses including cerebrovascular accident (CVA - a stroke) with weakness. The "History And Physical," dated and signed by his physician on March 2, 2018, indicated the resident "...Has the capacity to understand and make decisions." The baseline care plan dated February 28, 2018, indicated the activity of daily living (ADL) for grooming/hygiene required one person assistance. On April 5, 2018, the facility's policy and procedure titled, "Assisting the Nurse in Examining and Assessing the Resident," dated September 2010, was reviewed. The policy indicated, "...The purpose of this procedure is to assist the nurse in gathering information about the overall condition of the resident and his or her performance of activities of daily living...non-licensed nurses obtain important information about the resident in their daily observations and interaction...During your daily contact with the resident, be observant of the resident's level of independence in performing ADL...Assistance needed with...and nail care..."

F684 SS=D Quality of Care CFR(s): 483.25

F684 05/17/2018 § 483.25 Quality of care FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z11 Facility ID: CA240000081 If continuation sheet 27 of 44 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: _______________ 555884 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr 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 Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed, for one of 27 sampled residents (Resident 32), to ensure the weekly weights was performed as ordered by the physician. This failure had the potential for a delay in the treatment of Resident 32's weight loss. Findings: On April 2, 2018, at 12:30 p.m., Resident 32 was observed in the dining room being assisted by a staff to eat his meal. Resident 32 was able to feed himself but needed constant cueing by the staff to eat. On April 3, 2018, Resident 32's record was reviewed. Resident 32 was admitted to the facility on July 6, 2017, with diagnoses that included adult failure to thrive (state of decline in weight which may be caused by chronic diseases and functional impairments) and dementia (memory loss). The Registered Dietician (RD) progress notes, dated March 13, 2018, indicated, "...CNA (Certified Nursing Assistant) reports he eats bites...March wt (weight) 158 lbs (pounds)...with severe wt. loss (-10.2%) x (in) 3 mos. (months)...Rec. (recommendation) weekly wts. x 4 weeks..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z11 Facility ID: CA240000081 If continuation sheet 28 of 44 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: _______________ 555884 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr 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 The physician's order, dated March 22, 2018, indicated, "...WEEKLT [sic.] WTS X 4 WEEKS". There was no documented evidence the weekly weights were conducted as ordered by the physician on March 22, 2018. On April 3, 2018, at 9:30 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated the Restorative Nurse Assistant (RNA) 1 did the weekly weights for the residents and she usually gave them a copy of the result every week. LVN 1 stated the nurse should document on the resident's chart the result of the weekly weight. LVN 1 stated she did not find documentation of Resident 32's weekly weights in his chart. On April 3, 2018, at 10: a.m., RNA 1 was interviewed. RNA 1 stated Resident 32 was not on the list of residents with weekly weights orders. RNA 1 stated if the physician's order for weekly weights was ordered on March 22, 2018, the first weight would have been taken on March 26, 2018, then every Monday after that. RNA 1 stated she was not informed Resident 32 had an order for weekly weights on March 22, 2018. On April 4, 2018, at 10:19 a.m., the Director of Nursing (DON) was interviewed. The DON stated recommendations from the registered dietician should be implemented "right away" and new orders should be communicated to the staff. The DON stated Resident 32's order for weekly weights on March 22, 2018, should have been implemented by the staff.

F756 SS=D Drug Regimen Review, Report Irregular, Act On CFR(s): 483.45(c)(1)(2)(4)(5)

F756 05/17/2018 §483.45(c) Drug Regimen Review. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z11 Facility ID: CA240000081 If continuation sheet 29 of 44 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: _______________ 555884 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr 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 §483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. §483.45(c)(2) This review must include a review of the resident's medical chart. §483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. §483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z11 Facility ID: CA240000081 If continuation sheet 30 of 44 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: _______________ 555884 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr 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 failed to ensure monthly medication regimen review (MRR) by the Consultant Pharmacist (CP) addressed in his/her recommendations the therapeutic duplications involving multiple antipsychotic medications for one of five sampled residents (Resident 52). Findings: Resident 52's medical record was reviewed on April 4, 2018. The resident was admitted on February 5, 2018, with diagnoses including schizophrenia (severe mental disorder affecting thought process and behavior) with the following prescribed medications continued from the hospital: - Seroquel (medication to treat schizophrenia) 100 mg (milligram) one half tablet (50 mg) every morning and 400 mg one tablet by mouth every day at bedtime for schizophrenia manifested by responding to internal stimuli causing to strike out towards others; and - Risperdal 0.5 mg tablet one tablet at bed time for psychosis manifested by auditory hallucinations (hearing voices that are not real). In an interview on April 5, 2018, at 9:10 a.m., NP 1, a Nurse Practitioner, stated he based his clinical decisions on the input from the resident's family members, facility staff, the hospital admission orders, discussion with the psychiatrist, and other factors in determining the need for the continuation of antipsychotic medications. NP 1 also stated if the antipsychotic medications were continuation from the hospital, he would not change them. There was no documented evidence the resident's medical record included the clinical rationale for the resident's receiving two antipsychotic medications in the same class. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z11 Facility ID: CA240000081 If continuation sheet 31 of 44 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: _______________ 555884 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr 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 In an interview on April 4, 2018, 3:25 p.m., the CP stated he made recommendations about the use of two antipsychotic medications and spoke about it verbally on several occasions but was frustrated the recommendations were not addressed or acted on. The CP stated he did not make any recommendations in his MRR about the simultaneous use of two antipsychotic medications for Resident 52. The monthly MRR by the CP for February and March 2018 confirmed there was no recommendations specific to multiple antipsychotic use for the resident. According to "Practice Guideline for the Treatment of Patients with Schizophrenia, Second Edition," Copyright 2010, by American Psychiatric Association (APA), "... Antipsychotics Most reports on the combination of antipsychotics describe the effects of combinations with clozapine... Combinations of two or more antipsychotics, neither of which is clozapine, are also used frequently for treatment of schizophrenia. Some of this use reflects periods of cross-titration in the transition from one antipsychotic to another, but much of it represents long-term treatment. Evidence for (or against) this practice is minimal, as there are no controlled studies in the literature... The absence of evidence for combinations of antipsychotics does not mean that there are no patients who are best treated with such a combination. However, their use should be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z11 Facility ID: CA240000081 If continuation sheet 32 of 44 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: _______________ 555884 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr 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 justified by strong documentation that the patient is not equally benefited by monotherapy with either component of the combination. Practitioners should be aware of the problems inherent in combination therapies, including increased side effects and drug interactions as well as increased costs and decreased adherence..." The facility's policy and procedure titled, "Monthly Drug Regimen Review" approved, October 11, 2017, was reviewed and it indicated, "...DRR (drug regimen review) activities shall include...Duplication of medication orders include a written rationale for the duplication..."

F757 SS=D Drug Regimen is Free from Unnecessary Drugs CFR(s): 483.45(d)(1)-(6)

F757 05/17/2018 §483.45(d) Unnecessary Drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used§483.45(d)(1) In excessive dose (including duplicate drug therapy); or §483.45(d)(2) For excessive duration; or §483.45(d)(3) Without adequate monitoring; or §483.45(d)(4) Without adequate indications for its use; or §483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or §483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z11 Facility ID: CA240000081 If continuation sheet 33 of 44 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: _______________ 555884 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr 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 section. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure the residents were free from unnecessary medications when medications ordered for the same indication were not reviewed and clarified to prevent duplication of therapy in a timely manner for one of five sampled residents (Resident 52). Findings: Resident 52's medical record was reviewed on April 4, 2018. The resident was admitted to the facility on February 5, 2018, with the following pain medications ordered: - Tylenol 325 mg (milligram) two tablets by mouth every four (4) hours as needed for moderate pain (pain level between four and six (6) on a 0-10 scale) started on February 5, 2018; - Naproxen 250 mg tablet with food one tablet by mouth every 4 hours as needed for moderate pain (pain level between 4 and 6 on a 0-10 scale) started on February 5, 2018; and - Norco 10-325 mg one tablet by mouth every 4 hours as needed for moderate pain (pain level between 4 and 6 on a 0-10 scale). In an interview on April 4, 2018, at 11:30 a.m., RN 1 acknowledged the duplication of pain therapy and agreed there was no pain coverage for pain levels 1-3 and 7-10. Review of the Consultant Pharmacist's monthly Medication Regimen Review (MRR) for March 2018 included the following recommendation for Resident 52: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z11 Facility ID: CA240000081 If continuation sheet 34 of 44 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: _______________ 555884 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr 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 "The ibuprofen (another pain medication similar to ordered naproxen) and Norco orders are both currently indicated for moderate pain. Please clarify..." The CP's recommendation did not address the duplication of therapy with Tylenol and there was no CP recommendation made in the February 2018 MRR report. The facility's policy and procedure titled, "Monthly Drug Regimen Review," approved, October 11, 2017, was reviewed and it indicated, "DRR (drug regimen review) activities shall include...Duplication of medication orders include a written rationale for the duplication..."

F758 SS=D Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) 05/17/2018 §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z11 Facility ID: CA240000081 If continuation sheet 35 of 44 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: _______________ 555884 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr 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 §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure the residents were free from unnecessary psychotropic medications when more than one medication was ordered for the treatment of psychiatric diagnoses without documented rationale for their use to justify the benefit for two of five sampled residents (Residents 15 and 52) based on sound evidence-based literature or reference. Findings: 1. Resident 15's medical record was reviewed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z11 Facility ID: CA240000081 If continuation sheet 36 of 44 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: _______________ 555884 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr 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 on April 4, 2018. The resident was admitted on February 8, 2010, with diagnoses including psychosis, mood disorder, and impulse disorder with the following prescribed medications: - Invega (paliperidone, medication to treat various mental disorders) Susteena 156 mg (milligram) inject into muscle every four weeks on Wednesdays for psychosis manifested by delusions; and - Risperdal (risperidone, medication to treat various mental disorders) three mg one tablet by mouth every 12 hours for psychosis manifested by responding to internal stimuli (talking to self, yelling). According to the nationally recognized drug reference, Lexicomp Online, "...Paliperidone is considered a benzisoxazole atypical antipsychotic as it is the primary active metabolite of risperidone... ...Injection: Monthly IM. Note: Prior to initiation of monthly IM paliperidone, for patients naive to oral paliperidone or oral or injectable risperidone tolerability should be established with a test dose of oral paliperidone or oral risperidone. Previous oral antipsychotic regimen can be gradually discontinued at the time of initiation of monthly IM paliperidone... Use: Labeled Indications Schizophrenia: Treatment of Schizophrenia Schizoaffective disorder (oral and monthly IM paliperidone): Treatment of schizoaffective disorder as monotherapy and as an adjunct to mood stabilizers or antidepressants..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z11 Facility ID: CA240000081 If continuation sheet 37 of 44 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: _______________ 555884 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr 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 In an interview on April 5, 2018, at 9:10 a.m., Nurse Practitioner (NP) 1, stated he had seen and was familiar with the resident. NP 1 stated the reason the resident was receiving two antipsychotic medications in the same class was that one was a long acting injection and the other short acting tablet. NP 1 was not able to provide rationale justifying with supporting evidence use of two or more of antipsychotic medications applicable specifically to the resident. In an interview on April 4, 2018, at 3:25 p.m., the Consultant Pharmacist (CP) stated there had been number of verbal discussions on the use of two or more antipsychotic medications but no documented recommendations were included in the resident's medical record. 2. Resident 52's medical record was reviewed on April 4, 2018. The resident was admitted to the facility on February 5, 2018, with diagnoses including schizophrenia with the following prescribed medications continued from the hospital: -Seroquel (medication to treat a various mental disorder) 100 mg (milligram) one half tablet (50 mg) every morning and 400 mg one tablet by mouth every day at bedtime for schizophrenia manifested by responding to internal stimuli causing to strike out towards others; and - Risperdal (medication to treat a various mental disorder) 0.5 mg tablet one tablet at bed time for psychosis manifested by auditory hallucinations. In an interview on April 5, 2018, at 9:10 a.m., NP 1 stated he based his clinical decisions on the input from the patient's family members, facility staff, the hospital admission orders, discussion with the psychiatrist, and other FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z11 Facility ID: CA240000081 If continuation sheet 38 of 44 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: _______________ 555884 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr 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 factors in determining the need for the continuation of antipsychotic medications. NP 1 also stated if the antipsychotic medications were continued from the hospital he would not change them. There was no documented evidence in the resident's medical record of the clinical rationale for the resident's receiving two antipsychotic medications in the same class. In an interview on April 4, 2018, 3:25 p.m., the CP stated he made recommendations about the use of two antipsychotic medications and spoke about it verbally on several occasions but was frustrated the recommendations were not addressed or acted on. The CP stated he did not make any recommendations about the simultaneous use of two antipsychotic medications for Resident 52. According to "Practice Guideline for the Treatment of Patients with Schizophrenia, Second Edition," Copyright 2010, by American Psychiatric Association (APA), "... Antipsychotics Most reports on the combination of antipsychotics describe the effects of combinations with clozapine... Case series show improvements in residual positive symptoms with the addition of a number of other antipsychotics to clozapine. These agents include loxapine, pimozide, and risperidone... Combinations of two or more antipsychotics, neither of which is clozapine, are also used frequently for treatment of schizophrenia. Some FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z11 Facility ID: CA240000081 If continuation sheet 39 of 44 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: _______________ 555884 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr 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 of this use reflects periods of cross-titration in the transition from one antipsychotic to another, but much of it represents long-term treatment. Evidence for (or against) this practice is minimal, as there are no controlled studies in the literature. The largest case series includes six persons with inadequate responses to 2040 mg/ day of olanzapine, who had average decreases in BPRS and PANSS scores of 35% after addition of 60-600 mg/day of sulpiride for at least 10 weeks. Without a control group, such results are difficult to evaluate. Moreover, sulpiride is not available in the United States, and there is no way to know if similar results might be found with other antipsychotics. The absence of evidence for combinations of antipsychotics does not mean that there are no patients who are best treated with such a combination. However, their use should be justified by strong documentation that the patient is not equally benefited by monotherapy with either component of the combination. Practitioners should be aware of the problems inherent in combination therapies, including increased side effects and drug interactions as well as increased costs and decreased adherence..."

F759 SS=D Free of Medication Error Rts 5 Prcnt or More CFR(s): 483.45(f)(1)

F759 05/17/2018 §483.45(f) Medication Errors. The facility must ensure that its§483.45(f)(1) Medication error rates are not 5 percent or greater; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure residents were free from medication errors during FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z11 Facility ID: CA240000081 If continuation sheet 40 of 44 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: _______________ 555884 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr 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 medication pass by administering to Resident 62 after crushing an extended release (ER) medication and by administering to Resident 15 a thyroid medication after breakfast against the manufacturer's recommendation. The medication error rate was 6.25%. Findings: 1. During a medication pass observation on April 2, 2018, at 8:18 a.m., Licensed Vocational Nurse (LVN) 3 prepared 12 medications for Resident 62, crushed 10 medications including one extended release divalproex (medication for seizure) ER 500 mg, and administered, mixed in apple sauce, to the resident. In an interview on April 4, 2018, at 10:40 a.m., LVN 5 stated there was a physician order to crush all his medications and all his medications were crushed before administration. LVN 5 acknowledged the physician should have been consulted on the crushing of extended release medications. In an interview on April 4, 2018, at 3:25 p.m., the Consultant Pharmacist (CP) acknowledged the extended release medications should not be crushed. The facility's policy and procedure titled, "Medication Administration-General Guidelines" approved, October 11, 2017, was reviewed and it indicated, "...If it is safe to do so, mediation tablets may be crushed... Long-acting or enteric coated dosage forms should generally not be crushed; an alternative should be sought..." According to the manufacturer's drug label FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z11 Facility ID: CA240000081 If continuation sheet 41 of 44 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: _______________ 555884 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr 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 information on divalproex ER tablets, "...Divalproex sodium extended-release tablets are an extended-release product intended for once-a-day oral administration. Divalproex sodium extended-release tablets should be swallowed whole and should not be crushed or chewed..." 2. During a medication pass on April 4, 2018, 8:15 a.m., LVN 5 administered to Resident 15 medications including one tablet of levothyroxine (thyroid supplement for regulating body metabolism) 88 mcg (microgram). Review of the resident's medical record indicated the levothyroxine dose was scheduled to be administered at 6:30 a.m. once a day. In an interview on April 4, 2018, at 10:40 a.m., LVN 5 stated she was not able to administer earlier and acknowledged the medication was administered late. LVN 11 stated the resident had his breakfast around 7:30 a.m. LVN 11 agreed the medication should have been given before breakfast on an empty stomach. The facility's policy and procedure titled, "Medication Administration-General Guidelines," approved, October 11, 2017, was reviewed and it indicated, "...Medications shall be administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes..." According to the manufacturer's drug label information on levothyroxine tablets, "...Administer levothyroxine sodium tablets as a single daily dose, on an empty stomach, oneFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z11 Facility ID: CA240000081 If continuation sheet 42 of 44 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: _______________ 555884 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr 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 half to one hour before breakfast..."

F921 SS=D Safe/Functional/Sanitary/Comfortable Environ CFR(s): 483.90(i)

F921 05/17/2018 §483.90(i) Other Environmental Conditions The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, for one of 27 sampled residents (Resident 30), the facility failed to provide for a sanitary and functional toilet to use when maintenance staff was not called for repair for a clogged toilet in Room 5 over the weekend. This failure resulted to Resident 30 utilizing the toilet across his room (Room 8). Findings: On April 2, 2018, at 9:50 a.m., Resident 30 was observed entering Room 8 and had used the toilet. Resident 30 resided in Room 5. On April 2, 2018, at 9:55 a.m., Resident 30 verified he utilized the toilet in Room 8. On April 2, 2018, at 10:00 a.m., Certified Nursing Assistant's (CNA) 4 and CNA 5 (both CNA's were inside Room 5) were interviewed. Both CNA's stated the toilet in Room 5 was clogged over the weekend. On April 2, 2018, at 10:05 a.m., the Director of Staff Development (DSD) was interviewed. The DSD inspected and verified the toilet in Room 5 was clogged. DSD stated, he was not aware that the toilet in Room 5 was clogged over the weekend. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z11 Facility ID: CA240000081 If continuation sheet 43 of 44 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: _______________ 555884 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr 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 On April 2, 2018, at 10:10 a.m., the Maintenance Supervisor (MS) was interviewed. The MS stated, he only found out about the clogged toilet in Room 5 at 9:00 a.m. today. MD further explained, there was no maintenance personnel assigned to work over the weekend except to respond to maintenance emergencies. On April 4, 2018, at 9:43 a.m, Licensed Vocational Nurse (LVN) 7 was interviewed. The maintenance log book was reviewed with LVN 7. LVN 7 stated there was no record of entry made about the toilet in Room 5 being clogged over the weekend. On April 4, 2018, at 10:28 a.m., the MS was interviewed. MS stated, staff did not write down an entry notation in the maintenance log that the toilet in Room 5 needed to be repaired over the weekend. On April 4, 2018, at 2:58 p.m., the Director of Nursing (DON) was interviewed. The DON stated, a clogged toilet over the weekend was considered an emergency and should have been called for immediate repair. On April 5, 2018, the facility policy dated April 2010, titled, "Work Orders, Maintenance," was reviewed. The policy indicated, "...In order to establish a priority of maintenance service, work orders must be filled out...Emergency requests will be given priority ..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z11 Facility ID: CA240000081 If continuation sheet 44 of 44