Other·July 9, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated standard survey for the investigation of three complaints. Complaint number: CA00539683, CA00541846, and CA00543171. Representing the California Department of Public Health: Surveyor 35004, HFEN. The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Three deficiencies were issued for complaint numbers: CA00539683, CA00541846, and CA00543171.

F279 SS=D DEVELOP COMPREHENSIVE CARE PLANS CFR(s): 483.20(d);483.21(b)(1)

F279 04/20/2018 483.20 (d) Use. A facility must maintain all resident assessments completed within the previous 15 months in the resident’s active record and use the results of the assessments to develop, review and revise the resident’s comprehensive care plan. 483.21 (b) Comprehensive Care Plans (1) The facility must develop and implement a comprehensive person-centered care plan for 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: RK0M11 Facility ID: CA240000081 If continuation sheet 1 of 32 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 04/09/2018 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 each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c) (3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident’s medical record. (iv)In consultation with the resident and the resident’s representative (s)(A) The resident’s goals for admission and desired outcomes. (B) The resident’s preference and potential for future discharge. Facilities must document whether the resident’s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RK0M11 Facility ID: CA240000081 If continuation sheet 2 of 32 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 04/09/2018 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 requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to update/revise care plans regarding supervision/accidents after Resident A had aspirated (accidental sucking in of food particles or fluids into the lungs) food on April 12, 2017 and May 15, 2017, causing aspiration pneumonia (occurs when food, saliva, liquids, or vomit is breathed into the lungs or airways leading to the lungs, instead of being swallowed and going into the stomach) due to his inability to swallow. The failure to update and revise Resident A's care plans with new interventions for supervision caused the resident to choke and aspirate on a meatball June 12, 2017, resulting in the resident's death. Findings: On June 27, 2017, at 10:50 a.m., an unannounced complaint visit was conducted at the facility regarding a quality of care concern. The complaint intake indicated Resident A choked on a meatball and was sent to an acute care hospital for treatment. On June 27, 2017, at 11:33 a.m., the Registered Nurse Supervisor (RNS) was interviewed. The RNS stated Resident A was non-compliant with his NPO (nothing by mouth) diet due to swallowing difficulties. The RNS stated the resident (Resident A) required bolus feedings (a one time feeding as opposed to continuous feeding) through a gastrostomy tube (a tube placed directly into the stomach by surgery to provide nourishment and medications). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RK0M11 Facility ID: CA240000081 If continuation sheet 3 of 32 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 04/09/2018 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 RNS stated Resident A would pace from room to room and grab food from other residents. The RNS stated (Resident A's name) knew where the "feeders (residents that required staff to feed them) were, and he could walk independently. The RNS further stated that the resident was supposed to be monitored frequently by visual checks. On June 27, 2017, at 11:50 a.m., LVN 1 was interviewed. LVN 1 stated (Resident A's name) was nice and pleasant. She said the resident could not understand why he could not eat anything by mouth. She stated facility staff needed to be continuously behind him and redirect him all the time when he grabbed food from other residents. LVN 1 stated (Resident A's name) was everywhere around the facility and the staff would catch him "snatching food" from other residents. She said the facility did a speech evaluation, and (Resident A's name) failed twice. She could not recall the date. She said he was everywhere, outside, inside, in the restroom, and all over the facility. LVN 1 stated there was one time when the resident aspirated on food and she had seen white stuff, "like milk," coming out of his mouth, and speech therapy evaluated the resident for swallowing. He failed the swallow test. On June 27, 2017, at 12:07 p.m., LVN 2 was interviewed. LVN 2 stated, "A couple of months ago (Resident A's name) had aspiration pneumonia." She said the resident had been successful in getting food into his mouth. On June 27, 2017, at 1:48 p.m., the Certified Nurse Assistant (CNA) 1 was interviewed. CNA 1 stated she was assigned to (Resident A's name) on the day shift of June 12, 2017. CNA 1 stated he was not on frequent visual checks. CNA 1 stated she changed Resident A's diaper FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RK0M11 Facility ID: CA240000081 If continuation sheet 4 of 32 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 04/09/2018 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 before lunchtime and then around late 1 p.m., after lunch, she heard a page for "Code Blue." When CNA 1 entered the room (not Resident A's room), (LVN 1's name) was doing the Heimlich maneuver. CNA 1 stated Resident A had been walking around the facility's hallways before the incident occurred. She stated, (Resident A's name) "Always takes food," and he should have been closely watched. CNA 1 stated the resident should have been assigned a one to one caregiver for close supervision. On June 27, 2017, Resident A's record was reviewed. Resident A was admitted to the facility on March 3, 2017, with diagnoses that included dysphagia (difficulty swallowing), dementia (brain disease causing memory problems), and had a sudden cardiac arrest at his previous facility. The physician orders documented that Resident A was on a NPO diet with bolus tube feedings. A review of Resident A's care plan titled "...DYSPHAGIA," initiated on March 20, 2017, indicated Resident A had a swallowing impairment due to Alzheimer's or Dementia manifested by difficulty swallowing. The care plan indicated Resident A would grab food from other residents' trays and put food in his mouth. The care plan also indicated Resident A picked up food from other residents' trays and hid food in his clothes. The facility's interventions were to have a Speech Therapy (ST) evaluation and treatment as ordered and to remind the resident not to have food in his mouth. The interventions indicated for the speech therapist to evaluate for swallowing and for treatment of three days per week. The care plan also indicated speech therapy made a recommendation for Resident A to remain on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RK0M11 Facility ID: CA240000081 If continuation sheet 5 of 32 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 04/09/2018 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 NPO status. Resident A's care plan titled "SLP (Speech Licensed Practitioner) Therapy Treatment," initiated March 22, 2017, indicated Resident A was a high risk for aspiration due to a disease process that inhibited his swallowing abilities. The care plan indicated his swallowing difficulties were related to Alzheimer's Disease (brain disease causing memory problems). Resident A's care plan titled, "...Potential for injury: Aspiration," initiated in March (no date) 2017, indicated the resident had a potential for injury and aspiration of food related to impaired swallowing abilities. Facility interventions were to re-direct the resident away from the dining area and monitor his whereabouts. In addition, the staff needed to frequently remind the resident not to take food and put it in his mouth. A second care plan developed on April 12, 2017, indicated Resident A was a high risk for aspiration due to non-compliance of nothing by mouth. The care plan indicated to re-direct the resident to step out of the dining area and for a speech therapist to upgrade the diet due to resident's non-compliance. There were no new interventions in place that would delegate staff to supervise Resident A or to ensure that he was compliant with his NPO diet. The plan indicated the Speech Therapist's assessment to continue the NPO diet On May 16, 2017, the care plan was revised and indicated Resident A was a high risk for grabbing food from other residents' trays. The speech evaluation was done and indicated Resident A had difficulty managing his own saliva and poor safety awareness. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RK0M11 Facility ID: CA240000081 If continuation sheet 6 of 32 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 04/09/2018 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 facility's revised interventions were for staff to remind the resident not to grab food off of other residents' trays and to re-direct Resident A's attention. The care plan also indicated for facility staff to monitor the resident's whereabouts and to monitor the resident for any coughing and or aspiration. There were no new recommendations indicated in the new care plan pertaining in how the facility would monitor or supervise the resident. There was no detailed or individualized plan in how the facility staff were to delegate close supervision with the frequent grabbing of food and high risk for aspiration. There were no revisions made for the recent aspirated food incidents on April 12, 2017, and May 15, 2017. On July 3, 2017, at 11:28 a.m., LVN 3 was interviewed. LVN 3 stated "a couple of months ago", (Resident A's name) aspirated on food and was sent to the hospital for pneumonia. On July 3, 2017, at 11:40 a.m., LVN 4 was interviewed. LVN 4 stated Resident A would mainly go into certain rooms to get food from other residents. LVN 4 stated Resident A was supposed to be NPO, but he would "sneak" the food in his mouth and wait until nobody was looking. LVN 4 stated he usually would get caught, but he must be watched closely. LVN 4 stated the times he aspirated on food, the facility was required to revise the care plan and add new interventions. On February 1, 2018, the facility's policies titled "Care Plans-Comprehensive" and "Goals and Objectives, Care Plans," revised April 2009, were reviewed. "Care Plans-Comprehensive" indicated: "Policy Statement... FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RK0M11 Facility ID: CA240000081 If continuation sheet 7 of 32 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 04/09/2018 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 An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological need is developed for each resident. ...8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change." "Goals and Objectives, Care Plans" indicated: "Policy Statement... Care plans shall incorporate goals and objectives that lead to the resident's highest, obtainable level of independence... Policy Interpretation and Implementation... 1. Care plan goals and objectives are defined as the desired outcome for a specific resident problem... ...5. Goals and objectives are reviewed and/or revised a. When there has been a significant change in the resident's condition; b. When the desired outcome has not been achieved..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RK0M11 Facility ID: CA240000081 If continuation sheet 8 of 32 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 04/09/2018 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

F309 PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING CFR(s): 483.24, 483.25(k)(l)

F309 SS=G PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 05/09/2018 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident’s comprehensive assessment and plan of care. 483.25 Quality of care 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, including but not limited to the following: (k) Pain Management. The facility must ensure that pain management is provided to residents who require such FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RK0M11 Facility ID: CA240000081 If continuation sheet 9 of 32 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 04/09/2018 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 services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. (l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide supervision and necessary care for one of three sampled residents (Resident A) when Resident A, who was NPO (nothing by mouth) and known to steal food from other residents' meal trays, was found unresponsive and blue in a resident room. These deficient practices caused Resident A to choke on a meatball. The facility performed the Heimlich maneuver (a technique using abdominal thrusts in an attempt to remove a foreign body from the throat or windpipe of a choking person) for ten minutes before Resident A was checked for breathing which delayed initiation of CPR (Cardio-Pulmonary Resuscitation), resulting in irreversible brain damage and death of Resident A. Findings: On June 27, 2017, at 10:50 a.m., an unannounced complaint visit was conducted at the facility regarding a quality of care concern. On June 27, 2017, at 11:33 a.m., the Registered Nurse Supervisor (RNS) was interviewed. The RNS stated Resident A was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RK0M11 Facility ID: CA240000081 If continuation sheet 10 of 32 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 04/09/2018 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 non-compliant with his NPO diet because he could not eat due to swallowing difficulties. The RNS stated Resident A required bolus feedings (a one time feeding as opposed to continuous feeding) through a gastrostomy tube (a tube placed directly into the stomach surgically to provide nourishment and medications). The RNS stated Resident A would pace from room to room and grab food from other residents' food trays. The RNS stated Resident A knew where the "feeders (residents fed by staff) were." He said Resident A could walk independently and further stated the resident was supposed to be monitored frequently by visual checks. The RNS stated there were "a couple of times" the resident managed to get food in his mouth, but staff were able to remove the food before he choked. The RNS stated he heard an overhead page for "Code Blue (a page used to signal staff of a respiratory and/or cardiac arrest)" on June 12, 2017, around late morning. When he entered Room X, Resident A was unresponsive. He said LVN 1 was performing the Heimlich maneuver on Resident A. RNS stated LVN 1 was standing behind the resident, lifting him up while doing abdominal thrusts. He stated Resident A had chunks of food around his mouth. RNS said they failed to clear the resident's airway with the Heimlich maneuver so he called 911 (Emergency Medical Services paramedics). The RNS stated that after he called 911, he and LVN 1 laid the resident on the floor and performed CPR He said when the paramedics arrived, they took over CPR, intubated (a tube placed into the windpipe to provide ventilation) the resident and transported Resident A to the acute hospital. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RK0M11 Facility ID: CA240000081 If continuation sheet 11 of 32 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 04/09/2018 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 RNS stated later he received report from the acute care hospital that Resident A had choked on a "meatball." On June 27, 2017, at 11:50 a.m., Licensed Vocational Nurse 1 (LVN 1) was interviewed. She stated Resident A was, "Nice and pleasant," but could not understand why he could not have anything to eat by mouth. She said facility staff needed to be behind him continuously and re-direct him all the time when he grabbed food from other residents' trays. LVN 1 stated Resident A was everywhere around the facility and the staff caught him "snatching food" from other residents. She said the facility's Speech Therapist did an evaluation for Resident A's swallowing ability, and the resident failed it twice. LVN 1 further stated she heard a "stat (immediate)" page for Room X while she was in the dining room during lunch time on June 12, 2017. She said when she walked into the room, Resident A was leaning over the foot of the bed and was not responding. The room was not Resident A's. She stated she did a finger sweep of the resident's mouth and found nothing. LVN 1 said after the finger sweep was done, she managed to get the resident up on his feet and performed the Heimlich maneuver. When asked how long she performed abdominal thrusts, LVN 1 stated she was not sure, but it "Seemed like forever. Maybe ten minutes." She said Resident A was too heavy to carry so RNS helped her carry him while she performed the Heimlich maneuver. LVN 1 stated she was in a "panic mode," and that (Heimlich maneuver) was the first thing that came into her mind after finding him on the bed. She said the RNS called 911. She said she laid the resident on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RK0M11 Facility ID: CA240000081 If continuation sheet 12 of 32 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 04/09/2018 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 floor and started CPR. The RNS returned and helped with the chest compressions. LVN 1 stated, "EMS then arrived at the scene and helped with the CPR," and then took the resident to the hospital. On June 27, 2017, at 1:48 p.m., Certified Nurse Assistant (CNA) 1 was interviewed. CNA 1 stated she was assigned to Resident A on the day shift June 12, 2017. CNA 1 stated Resident A was not on frequent visual checks. She stated she changed Resident A's "diaper" before lunchtime and then around 1:30 p.m., after lunch, she heard the "Code Blue" page. When CNA 1 entered the room she saw LVN 1 doing the Heimlich maneuver. CNA 1 continued by saying the resident had been walking around the facility's hallways before the incident occurred. CNA 1 stated he "Always takes food." CNA 1 stated he should have been closely watched. She further stated the resident should have been assigned a one to one caregiver for close supervision. On June 27, 2017, at 2:10 p.m., the Director of Nursing (DON) was interviewed. The DON stated staffing was not an issue and the facility could have easily had a one to one care giver to increase supervision. The DON stated the Activities Assistant (AA) was the one who found Resident A first. The DON stated Resident A was found unresponsive and slumped over by the foot of the bed. The DON stated LVN 1 performed the Heimlich maneuver and RNS performed CPR. On June 27, 2017, Resident A's facility record was reviewed. Resident A was admitted to the facility on March 3, 2017, with diagnoses that included dysphagia (difficulty swallowing), dementia (brain disease causing memory problems), and had a sudden cardiac arrest at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RK0M11 Facility ID: CA240000081 If continuation sheet 13 of 32 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 04/09/2018 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 his previous facility. A review of the record titled "HISTORY AND PHYSICAL," dated March 22, 2017, indicated Resident A did not have the capacity to understand and make decisions. On June 27,2017, a form titled, "Physician Orders for Life-Sustaining Treatment (POLST)," dated March 22, 2017, indicated Resident A was to receive "Full Treatment (primary goal of prolonging life by all medically effective means)" in the case of a lifethreatening incident. The physician orders, for the month of June 2017, were reviewed and indicated, "...DIET: NPO; JEVITY (a tube feeding formula) 1.2 CAL (calories) BOLUS FEEDINGS... 3/22/17...ST (speech therapy)...order for TX (treatment) of Dysphagia (difficulty swallowing)...3/wk (three times a week) x 30 days... Resident A's care plans were reviewed and located care plans for "...Aspiration" (breathing a foreign substance into the lungs) and "Dysphagia," (difficulty swallowing) both dated in March (no date ) 2017. The care plan for aspiration indicated potential for injury and aspiration related to impaired swallow ability. The care plan indicated Resident A was non-compliant with his NPO diet order, picked up food from other resident's trays, and put the food items in his mouth. The care plan's goal indicated that Resident A would not have any incidents of aspiration for 90 days and lung sounds would remain clear. The facility interventions were to re-direct the resident to be away from the dining area at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RK0M11 Facility ID: CA240000081 If continuation sheet 14 of 32 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 04/09/2018 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 meal times, monitor the resident's whereabouts, and frequent reminders to not take food from others and not put the food in his mouth. The care plan for aspiration was revised on May 16, 2017, and indicated Resident A was a high risk for aspiration due to grabbing food from other trays. A speech evaluation was done on May 15, 2017 and indicated Resident A had difficulty managing his own saliva, had poor safety awareness and significant impaired cognition. The facility staffs' interventions were to have frequent reminders not to grab food from other residents' trays and to re-direct his attention during meal times. In addition, the staff were to provide different activities during mealtime and monitor his whereabouts/coughing and aspiration. A review of Resident A's care plan for dysphagia initiated on March 20, 2017, indicated Resident A had a swallowing impairment due to Alzheimer's or dementia manifested by difficulty swallowing. The care plan indicated Resident A would grab food and put the food in his mouth. The care plan also indicated Resident A picked up food on other residents' trays and hid food in his clothes. The facility's interventions were to have a ST evaluation and treatment as ordered and to remind the resident not to have food in his mouth. On April 12, 2017, the care plan was revised after the first swallow evaluation was completed by a speech therapist. The plan indicated Resident A was a high risk for aspiration due to non-compliance of nothing by mouth diet. The care plan further indicated Resident A failed the swallowing evaluation and was to continue the NPO diet. The care plan further indicated Resident A had increased FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RK0M11 Facility ID: CA240000081 If continuation sheet 15 of 32 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 04/09/2018 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 mouth opening and was unable to have labial (lip) seal during swallowing, had a consistent cough, immediate cough during food trials, and was unable to follow simple swallow instructions. The care plan further indicated for facility staff to encourage Resident A to refrain from putting food into his mouth, and to redirect the resident to step out from the dining area. A second swallowing screen was conducted on May 15, 2017. The report, "ST (Speech Therapist) Swallow Screen" indicated, "Pt (patient - Resident A) was referred to ST screen for possible po (oral) feeding. ST recommend to continue NPO with peg (Percutaneous Endoscopic Gastrostomy) feeding at this time to prevent aspiration and meet nutritional hydration needs. Pt is not a candidate for ST services, communicated to nursing for screen result." On May 16, 2017 an Interdisciplinary Team (IDT) meeting was conducted due to Resident A's behavior of "grabbing food on tray (sic) and other places. " There was no documented evidence of any new recommendations made by the IDT. On June 27, 2017, facility records titled "Departmental Notes," were reviewed for June 12, 2017, and indicated: -"AT 1:45 PM. RESIDENT WAS FOUND BY HOUSE KEEPING SLUMPED OVER FOOT OF BED. FOOD WAS FOUND ON BED, SWEEP OF MOUTH WAS DONE NO FOOD WAS FOUND. HEIMLICH MANEUVER (sic) WAS STARTED. 911 WAS CALLED. RESIDENT WAS NOT BREATHING, CPR WAS THEN STARTED. 1:55 PM, CONTINUED WITH CPR. NO VITALS NOTED. 2 PM PARAMEDICS ARRIVED. CONTINED (sic) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RK0M11 Facility ID: CA240000081 If continuation sheet 16 of 32 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 04/09/2018 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 WITH CPR. 2:10 PM RESIDENT WAS TAKEN TO (hospital name) VIA GURNEY. VITALS WERE OBTAINED PRIOR TO LEAVING..." An additional note written by the DON on June 12, 2017, read: "-6/12/2017...3:27 PM...Resident was found by staff slumped over the bed and appeared to have difficulty breathing around 1355 (1:55 p.m.). Code Blue was called, license nurses proceeded to resident room. Swept resident mouth, unable to obtain any food. Suction resident using Yankauer (the name of a suction tip), no secretion noted. Staff provided Heimlich (sic) maneuver to no avail. Pulse thread (sic) and weak. Resident turned cyanotic (blue color to the skin), breathing ceased. Placed resident on the floor, CPR initiated while other staff member called 911... arrived around 1400 (2 pm) with paramedics and took over patient care. IV (intravenous line) start to right knee via intra osseous (a needle that is injected directly into the bone marrow to allow fluids to get into circulation when a vein cannot be accessed), Hydration provided, Resident was intubated (placement of a tube down the windpipe so that artificial respirations can be provided) without difficulty. Able to obtain vitals sign (blood pressure and pulse) prior to transfer. Resident was placed in gurney and transfer to (hospital name omitted) per EMT (emergency medical technicians) @ 1415 (2:15 p.m.)." Review of the record titled "Patient Care Report," dated June 12, 2017, indicated the time of the cardiac arrest was at 1:40 p.m. and the call from the facility was received at 1:45 p.m. The paramedics were at the scene at 1:51 p.m. The primary impression was "airway obstruction and respiratory arrest." Further review of the paramedics records FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RK0M11 Facility ID: CA240000081 If continuation sheet 17 of 32 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 04/09/2018 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 at 1:51 p.m., the paramedics arrived at the scene of a 58 year old male in cardiac arrest and "pulseless electrical activity" on the EKG (electrocardiogram) machine. The record also indicated no blood pressure, pulse, or respirations on the paramedics' arrival. The paramedics administered Oxygen, epinephrine (a medication used during resuscitation of cardiac arrest), and intubated Resident A. The resident's pulse returned, and he was transported to the acute care hospital. On June 29, 2017, at 2:47 p.m., the AA (Activity Assistant) was interviewed. The AA stated before the activities started, he walked down the hallways to see if any residents wanted to join the activities the day of June 12, 2017. When the AA walked by Room X, he said he saw Resident A "lying long ways" on the bed, looking down. The AA stated Resident A's face was "blue," and was unable to talk or respond when talked to. The AA stated Resident A eyes were "white and rolled." The AA stated he pressed the call light and yelled for help. The AA grabbed the resident from the back and started to do the Heimlich maneuver. The AA stated Resident A was "not breathing" and was "blue." The AA stated he had never seen anybody with that kind of blue color before during his career as an activities assistant. The AA stated he saw an empty carton of milk by the bed. The AA stated LVN 1 took over, and while Resident A was already blue, she performed the Heimlich maneuver. The AA said the nurses laid Resident A onto the floor and performed CPR. He said they (staff) were "pumping for a while." The AA stated the paramedics took a while to get to the facility. On June 30, 2017, at 2:41 p.m., Resident A was observed in his hospital room. He was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RK0M11 Facility ID: CA240000081 If continuation sheet 18 of 32 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 04/09/2018 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 non-verbal and non-responsive when spoken to. Resident A's acute hospital records were reviewed. The acute hospital record titled "INTERNAL MEDICINE HISTORY AND PHYSICAL," dated June 12, 2017, indicated Resident A was brought in by EMS for choking. The acute care hospital documented that the resident had a G-tube and was not supposed to eat, but apparently was eating cookies and started to choke. Heimlich was performed and Resident A went apneic (stopped breathing), downtime about 8 minutes, CPR performed, 2 rounds of epi (epinephrine - a medication use in cardio-pulmonary arrest) given and King airway (a sterile tube inserted in the mouth used to provide artificial oxygenation) placed by EMS." A document written by the Emergency Department Physician (EDP) indicated that she (EDP) had removed a piece of "meatball" that measured four centimeters from Resident A's throat. A review of the facility's production menus, from June 12, 2017, until June 18, 2017, indicated on June 12, 2017, the facility served "Swedish meatballs" to the residents at lunch. A review of the acute hospital record titled "CRITICAL ARE PROGRESS NOTE," dated June 12, 2017, indicated Resident A had a diagnosis of irreversible brain injury with poor prognosis. Paperwork was submitted to the Bioethics Team (a group who review moral issues regarding life extension) for cessation of life support. Further review of the acute hospital record titled "BIOETHICS RECORD OF CASE REVIEW," dated June 15, 2017, indicated, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RK0M11 Facility ID: CA240000081 If continuation sheet 19 of 32 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 04/09/2018 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 "...Reason for Referral: Assistance with end of life and code status decisions for patient (Patient A) with Conservator..." The record went on to read EXPECTED OUTCOMES: Poor prognosis for functional recovery. Anticipate hospital-based death..." On July 3, 2017, at 11:22 a.m., the hospital LCSW was interviewed over the telephone. She stated Resident A had passed away on July 1, 2017. The LCSW said the Bioethics Team had removed life support from the resident so that he could pass peacefully. On August 1, 2017, EDP was interviewed over the telephone. The EDP stated Resident A was not supposed to eat. She said the facility nurses tried to perform the Heimlich maneuver. She said the resident was not intubated at the facility but had a King airway in place on arrival at the emergency room. The EDP stated she intubated (placement of a tube into the trachea (windpipe) to provide artificial ventilation) Resident A and found food that resembled a "meatball" on the back of the patient's throat by the vocal chords. She said it was round and had consistency of ground up meat. The EDP stated she was not able to talk to nursing at the facility but received a report from the paramedics that Resident A was on peg tube feedings and choked on food he had attempted to eat. On August 10, 2017, Resident A's record titled "Coroner Investigation," dated July 1, 2017, indicated Resident A had died on July 1, 2017, at 6:48 p.m. at the acute care hospital. The record further indicated, "...While en route (from the facility to the acute care hospital), Resident A was resuscitated and while in the Emergency Department, physicians were able to remove a piece of meatball from his airway. Resident A remained in a comatose state since FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RK0M11 Facility ID: CA240000081 If continuation sheet 20 of 32 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 04/09/2018 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 his admission and his condition never improved. Due to his poor prognosis, his physicians placed a do not resuscitate order on 07/01/2017 at 1123 (11:23 a.m.) hours due to Resident A having no known family to make healthcare decisions for him. He was then extubated (the tube in his windpipe was removed) at 1300 (1 p.m.) hours as part of a terminal wean (removal of all life support medications and devices) and continued to experience respiratory failure until he was pronounced dead at 1848 (6:48 p.m.) hours by (doctor's name)..." Further review of the "Coroner Investigation," dated July 2, 2017, indicated the causes of death were hypoxic encephalopathy (brain injury caused by oxygen deprivation to the brain) due to asphyxia (suffocation) and choking on food. Other significant conditions contributing to his death were dysphagia. On August 7, 2017, Resident A's death certificate, dated July 14, 2017, indicated the resident's causes of death on July 1, 2017, 19 days after choking on a meatball, were hypoxic encephalopathy, asphyxia, and choking on food.

F323 SS=G FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3)

F323 04/20/2018 (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RK0M11 Facility ID: CA240000081 If continuation sheet 21 of 32 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 04/09/2018 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 accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to provide adequate supervision for one resident (Resident A) in a sample of three residents who was known to be an aspiration risk and compulsive food seeker. This failure caused Resident A to choke on another resident's food, become unresponsive, require CPR (cardio- pulmonary resuscitation) with transportation to the acute care hospital via paramedic ambulance where the resident died 19 days later due to anoxic brain injury (no oxygen supplied to the brain). Findings: On June 27, 2017, at 10:50 a.m., an unannounced complaint visit was conducted at the facility regarding a quality of care concern. The complaint intake indicated Resident A had choked on a meatball and was sent to an acute care hospital. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RK0M11 Facility ID: CA240000081 If continuation sheet 22 of 32 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 04/09/2018 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 June 27, 2017, at 11:33 a.m., the Registered Nurse Supervisor (RNS) was interviewed. The RNS stated Resident A was non-compliant with his diet because he could not eat due to swallowing difficulties. The RNS stated Resident A required bolus feedings (a one time feeding as opposed to continuous feeding) via gastrostomy tube (a tube placed directly into the stomach by surgery to provide nourishment, liquids, and medications). The RNS stated Resident A would pace from room to room and grab food from other residents' food trays. The RNS stated the resident knew where the "feeders (residents fed by staff) were" He stated Resident A could walk independently. The RNS further stated the resident was supposed to be monitored frequently by visual checks, but he managed to get food into his mouth a "couple of times." The RNS said staff were able to remove the food on those occasions before he choked. Around late morning on June 12, 2017, the RNS stated he heard an overhead page for "Code Blue (a page used to signal a respiratory and/or cardiac arrest) to alert staff at the facility," around late morning. He said when he entered Room X (not resident's room), Resident A was unresponsive. He said Licensed Vocational Nurse 1 (LVN ) was performing the Heimlich maneuver (a technique using abdominal thrusts to remove a foreign body such as food from the throat or windpipe of a choking person) on Resident A. The RNS stated LVN 1 was standing behind the resident, lifting him up while doing abdominal thrusts. He stated Resident A had chunks of food around his mouth when they tried to suction his mouth. RNS said they failed to clear the resident's airway with the Heimlich maneuver so he called 911 (Emergency Medical Services). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RK0M11 Facility ID: CA240000081 If continuation sheet 23 of 32 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 04/09/2018 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 RNS stated that after he called 911, he and LVN 1 laid the resident on the floor and performed CPR (Cardio-Pulmonary Resuscitation). He said when the paramedics arrived, they took over CPR. The RNS said the paramedics intubated (a tube placed into the windpipe to provide artificial ventilation) the resident and transported (Resident A's name) to the acute care hospital. The RNS stated later he received report from the acute care hospital that Resident A choked on "meatball." On June 27, 2017, at 11:50 a.m., LVN 1 was interviewed. LVN 1 stated Resident A was nice and pleasant, but could not understand that he could not have anything to eat by mouth. She stated facility staff needed to be continuously behind him and re-direct him all the time when he grabbed food from other residents' food trays. LVN 1 stated Resident A was everywhere around the facility. Staff caught him "snatching food" from other residents. LVN 1 stated the facility had a swallow evaluation done by a speech therapist, and he failed it twice. LVN 1 stated she heard a "Stat (immediately)" page while she was in the dining room on June 12, 2017. She stated when she walked into the room, (Resident A's name) was leaning over the foot of the bed and was not responding. She said the room belonged to one of his friends where he knew he could get food. LVN 1 stated (Resident A's name) "had a girlfriend" and that resident thought the resident was her husband. LVN 1 stated the staff told the resident that "he cannot eat," but the staff needed to constantly watch her room and the dining room and always "be behind him." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RK0M11 Facility ID: CA240000081 If continuation sheet 24 of 32 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 04/09/2018 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 LVN 1 stated when she found the resident, she did a finger sweep in (Resident A's name) mouth and found nothing. Then, she said she managed to get Resident A up on his feet and performed the Heimlich maneuver, but that did not clear his airway (Resident A). On June 27, 2017, at 1:48 p.m., the Certified Nurse Assistant 1 (CNA) was interviewed. CNA 1 stated she was assigned to Resident A on the day shift of June 12, 2017. She stated Resident A was not on frequent visual checks. CNA 1 stated she changed his diaper before lunchtime and then around 1 p.m., after lunch, she heard the "Code Blue" page. When CNA 1 entered Room X, LVN 1 was doing the Heimlich maneuver. CNA 1 stated Resident A had been walking around the facility's hallways before the incident occurred. CNA 1 stated Resident A "Always takes food." She said he should have been closely watched. CNA 1 stated Resident A name should have been assigned a one to one caregiver for close supervision. On June 29, 2017, at 2:47 p.m., the Activity Assistant (AA) was interviewed. The AA stated before the activities started, he walked down the hallways to see if any residents wanted to join the activities the day of June 12, 2017, around after lunch. When the AA walked by Room X which was not the resident's room, he noticed the Housekeeping staff (IHS) staring outside the room. When the AA entered Room 1, he observed Resident A "lying long ways" on the bed, looking down. The AA stated Resident A's face was "blue," and he was unable to talk and respond when talked to. The AA stated Resident A's eyes were "white and rolled." The AA stated he pressed the call light and yelled for help. The AA grabbed Resident A from the back and started to do the Heimlich maneuver. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RK0M11 Facility ID: CA240000081 If continuation sheet 25 of 32 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 04/09/2018 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 AA stated Resident A was "not breathing" and was "blue." The AA stated he had, "Never seen anybody with that kind of color blue before during his career as an activities assistant." The AA stated he saw an empty carton of milk by the bed. Resident A's facility record was reviewed. Resident A was admitted to the facility on March 3, 2017, with diagnoses that included dysphagia (difficulty swallowing), dementia (brain disease causing memory problems), and suffered from a sudden cardiac arrest while in another facility. A review of the resident's facility record titled "HISTORY AND PHYSICAL," dated March 22, 2017, indicated Resident A did not have the capacity to understand and make decisions. Resident A's facility record titled "Physician Orders for Life-Sustaining Treatment (POLST)," dated March 22, 2017, indicated Resident A was to receive "Full Treatment (primary goal of prolonging life by all medically effective means)." A review of Resident A's care plan titled "...DYSPHAGIA," initiated on March 20, 2017, indicated Resident A had a swallowing impairment due to Alzheimer's or Dementia manifested by difficulty swallowing. The care plan indicated Resident A would grab food and put food in his mouth. The care plan also indicated Resident A picked up food from other residents' trays and hid the food in his clothes. The facility's interventions were to have a Speech Therapy (ST) evaluation and treatment as ordered and to remind the resident not to have food in his mouth... On April 12, 2017, a note written by a speech therapist was reviewed. The note indicated that the therapist had assessed the resident's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RK0M11 Facility ID: CA240000081 If continuation sheet 26 of 32 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 04/09/2018 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 swallow functions for his ability to take food by mouth since he consistently rummaged for po (oral) foods. Per ST Resident A had physical impairments (such as inability to control his saliva and/or close his lips around an object). The Speech Therapist determined the resident was at risk for aspiration, further decline in functions, and decreased participation. A review of the facility's records titled "Departmental Notes," dated May 1, 2017, at 9:48 a.m.,documented an "IDT (Interdisciplinary Team - consisting of member from optional services provided in the facility) Review 4/29/17 at 5:35 Pm (sic) indicated, " CNA notified CN (Charge Nurse) that resident was struck on the right side of his neck while attempting to take another residents food in the dining area. residnet (sic) is noted to take or pick at food. will cont (continue) to monitor..." The On June 9, 2017, the Departmental Notes written by nursing indicated that at 2:30 AM "...Resident was pacing up and down hallway and bathroom; he was redirected several times but another resident became agitated and smacked him on his shoulder; no injury noted; IDT recommends: Monitor whereabouts; psych (psychiatrist) consult r/t (related to) pacing; inability to sleep..." On June 12, 2017, at 2:28 p.m., the "Departmental Notes," indicated, "AT 1:45 PM. RESIDENT WAS FOUND BY HOUSE KEEPING SLUMPED OVER FOOT OF BED. FOOD WAS FOUND ON BED, SWEEP OF MOUTH WAS DONE NO FOOD WAS FOUND. HEIMLACH MANEUVAR (sic) WAS STARTED. 911 WAS CALLED. RESIDENT WAS NOT BREATHING, CPR WAS THEN STARTED. 1:55 PM, CONTINUED WITH CPR. NO VITALS NOTED. 2 PM FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RK0M11 Facility ID: CA240000081 If continuation sheet 27 of 32 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 04/09/2018 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 PARAMEDICS ARRIVED. CONTINED (sic) WITH CPR. 2:10 PM RESIDENT WAS TAKEN TO (hospital name) VIA GURNEY. VITALS WERE OBTAINED PRIOR TO LEAVING..." On June 27, 2017, a review of the facility's production menus, from June 12, 2017, until June 18, 2017, had been completed. The menus indicated the facility served "Swedish meatballs" to the residents for lunch on June 12, 2017. On June 30, 2017, Resident A's records from the general acute care hospital were reviewed. A review of the acute hospital record titled "INTERNAL MEDICINE HISTORY AND PHYSICAL," dated June 12, 2017, indicated Resident A was brought in by EMS (emergency medical services) for choking. Resident A had a G-tube and was not supposed to eat, but apparently was eating cookies and started to choke. Heimlich was performed and went apneic (stopped breathing), downtime about 8 minutes, CPR performed, 2 rounds of epi (epinephrine) given and King airway (artificial airway) placed by EMS. In the emergency department, the doctor removed a piece of meatball. On July 3, 2017, at 11:28 a.m., LVN 2 was interviewed. LVN 2 stated, "A couple of months before" Resident A aspirated on food and was sent to the hospital for pneumonia caused by the aspiration. LVN 2 said the resident was not on frequent visual checks. She stated Resident A had an altercation with another resident for entering his room and the other resident hit him on the shoulder. She further stated Resident A should have been on every 15 minute visual checks. The facility's policy titled "Safety and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RK0M11 Facility ID: CA240000081 If continuation sheet 28 of 32 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 04/09/2018 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 Supervision of Residents," revised December 2007, indicated: "...Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facilitywide priorities... Facility-Oriented Approach to Safety... Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QA&A reviews of safety and incident/accident reports; and a facility wide commitment to safety and incident/accident reports, and a facility-wide commitment to safety at all levels of the organization... When accident hazards are identified, the QA&A/Safety Committee shall evaluate and analyze the cause(s) of the hazards and develop strategies to mitigate or remove the hazards to the extent possible... Employees shall be trained and inserviced on potential accident hazards and how to identify and report accident hazards, and try to prevent avoidable accidents... Resident-Oriented Approach to Safety... Staff shall use various sources to identify risk factors for residents, including the information obtained from the medical history, physical exam, observation of the resident, and the MDS (Minimum Data Set)... The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RK0M11 Facility ID: CA240000081 If continuation sheet 29 of 32 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 04/09/2018 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 hazards or risks for that resident. The care team shall target interventions to reduce the potential for accidents... Implementing interventions to reduce accident risks and hazards shall include the following... Communicating specific interventions to all relevant staff... Assigning responsibility for carrying out interventions... Providing training, as necessary... Ensuring that interventions are implemented... Documenting interventions... Monitoring the effectiveness of interventions shall include the following... Ensuring that interventions are implemented correctly and consistently... Evaluating the effectiveness of interventions... Modifying or replacing interventions as needed; and... Evaluating the effectiveness of new or revised interventions... Systems Approach to Safety... The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly... FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RK0M11 Facility ID: CA240000081 If continuation sheet 30 of 32 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 04/09/2018 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 supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment... The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment...or if there is a change in the resident's condition..." A review of the record titled "Coroner Investigation," dated July 1, 2017, indicated Resident A had died on July 1, 2017, at 6:48 p.m. at the acute care hospital. The record further indicated, "...While en route, Resident A was resuscitated and while in the Emergency Department, physicians were able to remove a piece of meatball from his airway. Resident A remained in a comatose state since his admission and his condition never improved. Due to his poor prognosis, his physicians placed a do not resuscitate order on 07/01/2017 at 1123 (11:23 a.m.) hours due to Resident A having no known family to make healthcare decisions for him. He was then extubated (the artificial airway tube was removed) at 1300 (1 p.m.) hours as part of a terminal wean and continued to experience respiratory failure until he was pronounced dead at 1848 (6:48 p.m.) hours by (doctor's name omitted)..." Resident A died 19 days after he had choked on the meatball. Further review of the "Coroner Investigation," dated July 2, 2017, indicated the causes of death were hypoxic encephalopathy (brain injury caused by lack oxygen to the brain) due to asphyxia (suffocation) and choking on food. Other significant conditions contributing to his FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RK0M11 Facility ID: CA240000081 If continuation sheet 31 of 32 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 04/09/2018 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 death were dysphagia. Resident A's death certificate, dated July 14, 2017, indicated the causes of Resident A's death were hypoxic encephalopathy, asphyxia, and choking on food. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RK0M11 Facility ID: CA240000081 If continuation sheet 32 of 32