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 to investigate two complaints. Complaint numbers: CA00585931 and CA00588044 Representing the California Department of Public Health: Surveyor 34388, HFEN The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Four deficiencies were issued for complaint numbers: CA00585931 and CA00588044

F608 SS=D Reporting of Reasonable Suspicion of a Crime F608 CFR(s): 483.12(b)(5)(i)-(iii) 07/05/2018 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. (i) Annually notifying covered individuals, as defined at section 1150B(a)(3) of the Act, of that individual's obligation to comply with the following reporting requirements. (A) Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who 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: PTDQ11 Facility ID: CA240000081 If continuation sheet 1 of 17 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 06/05/2018 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 is a resident of, or is receiving care from, the facility. (B) Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. (ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act. (iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to report an incident of alleged sexual abuse for one of four sampled residents (Resident A) in a universe of 63 residents. This failure occurred when Resident A made an accusation of being raped and no report of the alleged violation was made to the State Agency or other agencies as required. This failure had the potential to result in psychosocial harm for Resident A and other facility residents. Findings: On May 8, 2018, at 11:17 a.m., an unannounced visit was made to the facility for the investigation of an anonymous complaint regarding resident abuse. On May 17, 2018, Resident A's facility medical record was reviewed. Resident A was admitted to the facility on January 26, 2018, with diagnoses that included osteoarthritis (flexible FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PTDQ11 Facility ID: CA240000081 If continuation sheet 2 of 17 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 06/05/2018 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 tissue at the ends of bones wears down), muscle weakness, and paranoid schizophrenia (a chronic mental disorder in which a person loses touch with reality). Review of Resident A's facility, "History and Physical," (H&P), dated January 29, 2018, indicated, "This resident has fluctuating capacity to understand and make decisions." Further review of Resident A's facility record found a nursing progress note dated April 8, 2018, at 12:22 a.m., that indicated, "Approximately 1130 when preforming (sic) rounds noted resident in supine position (laying on the back) on floor next to bed, unable to determine if have fallen or layed (sic) herself on to (sic) floor. Eyes open and fixated to right side with involuntary tremoring generalized to affected hands arms (sic) face and legs...Resident came through catatonic state (syndrome marked by an inability to move normally) and got up and began to run down the hall verbalizing she was rape (sic) and had hit her head and wanted to get away from nurses. Attempted to re-direct resident in calming approach deemed ineffected (sic) and was activity (sic) screaming believing anyone whom (sic) came close to her was to do harm...Resident was noted to be visably (sic) shaking uncontrollably, unrelieve (sic) with verbal assurance..." The note further indicated, "...Upon arrival of first responder questioned resident, stated that she hit her head and that she was raped..." Review of a facility Interdisciplinary Note for Resident A dated April 9, 2018, indicated, "...IDTeam (interdisciplinary team) met today regarding an incident on 4/7/2018 at around FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PTDQ11 Facility ID: CA240000081 If continuation sheet 3 of 17 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 06/05/2018 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 11:30 PM, where this resident was found on the floor next to her bed, laying position (sic) with episodes of tremors, catatonic state initially but able to stand up and run in hallway, screaming, stating tht (sic) she was raped and that she had hit her head..." Further review of the Interdisciplinary Note indicated, "...This resident had denied being raped when interviewed again. She denied stating that she was sexually abused..." Review of a second Interdisciplinary Note for Resident A also dated April 9, 2018, indicated, "After further investigation, it has been concluded that the resident possible (sic) had a tremor episode causing her to fall on the floor on 4/7/2018. It has also been concluded that there was NO sexual abuse that occurred as the resident denied that she had stated that she was raped after re-interview. There was no evidence as well that supports her initial claim..." Review of Resident A's facility progress notes found an addendum dated April 12, 2018, at 11:45 a.m., that indicated, "When interview resident second (sic) time in regards to resident found on floor, resident verbalized nothing happen (sic). Resident continue to be disorientated." Further review of Resident A's facility medical record found no documentation that indicated the State Agency or law enforcement agencies had been notified of Resident A's allegation of rape. There was no documentation found that indicated the State Agency had been notified of the investigation conducted by the facility regarding the resident's allegation of rape. There was no documentation to indicate that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PTDQ11 Facility ID: CA240000081 If continuation sheet 4 of 17 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 06/05/2018 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 had been examined for signs of sexual activity/abuse. On May 17, 2018, at 9:40 a.m., an interview was conducted with the facility Administrator (AD). The AD was asked if Resident A's allegation of rape had been reported. The AD stated, "No." The AD further stated, "they did not believe" that the rape had occurred and stated that the resident when asked later about the allegation did not remember making the allegation. On May 17, 2018, at 3:34 p.m., an interview was conducted with the AD and the Director of Nursing (DON). The AD and DON were asked if an allegation of rape is considered an allegation of abuse that should be reported. The AD stated, "Yes, of course." Review if the facility policy titled, "Abuse Prevention Program," revised August 2006, indicated, "...Our residents have the right to be free from abuse, neglect...g. The reporting and filling of accurate documents relative to incidents of abuse..." Review of the facility policy titled, "Protection of Residents During Abuse Investigation," revised December 2006, indicated, "...2.Within five (5) working days of the alleged incident, the facility will give the resident, the resident's representative (sponsor), the ombudsman, state survey and certification agencies...a written report of the findings of the investigation and a summary of a corrective action..."

F609 Reporting of Alleged Violations FORM CMS-2567(02-99) Previous Versions Obsolete

F609 Event ID: PTDQ11 07/05/2018 Facility ID: CA240000081 If continuation sheet 5 of 17 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 06/05/2018 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) SS=D CFR(s): 483.12(c)(1)(4) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to ensure that it reported an alleged abuse to the State Survey Agency no later than 24 hours after the allegation of sexual abuse was made for one of four sampled residents (Resident A) in a universe of 63 residents. This failure occurred when Resident A made an accusation that she had FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PTDQ11 Facility ID: CA240000081 If continuation sheet 6 of 17 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 06/05/2018 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 been raped and no report of the alleged violation was made to the State Agency or other agencies as required. Findings: On May 8, 2018, at 11:17 a.m., an unannounced visit was made to the facility for the investigation of an anonymous complaint regarding resident abuse. On May 17, 2018, Resident A's facility medical record was reviewed. Resident A was admitted to the facility on January 26, 2018, with diagnoses that included osteoarthritis (flexible tissue at the ends of bones wears down), muscle weakness, and paranoid schizophrenia (a chronic mental disorder in which a person loses touch with reality). Review of Resident A's facility, "History and Physical," (H&P), dated January 29, 2018, indicated, "This resident has fluctuating capacity to understand and make decisions." Further review of Resident A's facility record found a nursing progress note dated April 8, 2018, at 12:22 a.m., that indicated, "Approximately 1130 when preforming (sic) rounds noted resident in supine position (laying on the back) on floor next to bed, unable to determine if have fallen or layed (sic) herself on to (sic) floor. Eyes open and fixated to right side with involuntary tremoring generalized to affected hands arms (sic) face and legs...Resident came through catatonic state (syndrome marked by an inability to move normally) and got up and began to run down FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PTDQ11 Facility ID: CA240000081 If continuation sheet 7 of 17 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 06/05/2018 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 hall verbalizing she was rape (sic) and had hit her head and wanted to get away from nurses. Attempted to re-direct resident in calming approach deemed ineffected (sic) and was activity (sic) screaming believing anyone whom (sic) came close to her was to do harm...Resident was noted to be visably (sic) shaking uncontrollably, unrelieve (sic) with verbal assurance..." The note further indicated, "...Upon arrival of first responder questioned resident, stated that she hit her head and that she was raped..." Review of a facility Interdisciplinary Note for Resident A dated April 9, 2018, indicated, "...IDTeam (interdisciplinary team) met today regarding an incident on 4/7/2018 at around 11:30 PM, where this resident was found on the floor next to her bed, laying position (sic) with episodes of tremors, catatonic state initially but able to stand up and run in hallway, screaming, stating tht (sic) she was raped and that she had hit her head..." Further review of the Interdisciplinary Note indicated, "...This resident had denied being raped when interviewed again. She denied stating that she was sexually abused..." Review of a second Interdisciplinary Note for Resident A also dated April 9, 2018, indicated, "After further investigation, it has been concluded that the resident possible (sic) had a tremor episode causing her to fall on the floor on 4/7/2018. It has also been concluded that there was NO sexual abuse that occurred as the resident denied that she had stated that she was raped after re-interview. There was no evidence as well that supports her initial claim..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PTDQ11 Facility ID: CA240000081 If continuation sheet 8 of 17 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 06/05/2018 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 Review of Resident A's facility progress notes found an addendum dated April 12, 2018, at 11:45 a.m., that indicated, "When interview resident second (sic) time in regards to resident found on floor, resident verbalized nothing happen (sic). Resident continue to be disorientated." Further review of Resident A's facility medical record found no documentation that indicated the State Agency or law enforcement agencies had been notified of Resident A's allegation of rape. There was no documentation found that indicated the State Agency had been notified of the investigation conducted by the facility regarding the resident's allegation of rape. There was no documentation to indicate that Resident A had been examined for signs of sexual activity/abuse. On May 17, 2018, at 9:40 a.m., an interview was conducted with the facility Administrator (AD). The AD was asked if Resident A's allegation of rape had been reported. The AD stated, "No." The AD further stated, "they did not believe" that the rape had occurred and stated that the resident when asked later about the allegation did not remember making the allegation. On May 17, 2018, at 3:34 p.m., an interview was conducted with the AD and the Director of Nursing (DON). The AD and DON were asked if an allegation of rape is considered an allegation of abuse that should be reported. The AD stated, "Yes, of course." Review if the facility policy titled, "Abuse Prevention Program," revised August 2006, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PTDQ11 Facility ID: CA240000081 If continuation sheet 9 of 17 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 06/05/2018 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, "...Our residents have the right to be free from abuse, neglect...g. The reporting and filling of accurate documents relative to incidents of abuse..." Review of the facility policy titled, "Protection of Residents During Abuse Investigation," revised December 2006, indicated, "...2.Within five (5) working days of the alleged incident, the facility will give the resident, the resident's representative (sponsor), the ombudsman, state survey and certification agencies...a written report of the findings of the investigation and a summary of a corrective action..."

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 07/05/2018 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PTDQ11 Facility ID: CA240000081 If continuation sheet 10 of 17 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 06/05/2018 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 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 requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to develop and implement comprehensive person-centered care plans for two of three sampled residents (Residents C and D) in a universe of 63 residents that addressed the residents individualized activity preferences that included measurable objectives and timeframes to meet the resident's mental and psychosocial needs. Findings: On May 24, 2018, at 2:00 p.m., an unannounced visit was made to the facility for the investigation of a complaint regarding quality of life. On May 24, 2018, Resident C's facility medical record was reviewed. Resident C was admitted to the facility on March 13, 2018, with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PTDQ11 Facility ID: CA240000081 If continuation sheet 11 of 17 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 06/05/2018 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 diagnoses that included cerebral infarction (brain lesion where clusters of brain cells die with insufficient supply of blood), type 2 diabetes mellitus (condition that affects the way the body processes blood sugar), and psychoactive substance abuse (drug abuse). Review of Resident C's facility, "History and Physical," (H&P), dated May 20, 2018, indicated, "This resident has the capacity to understand and make decisions." Further review of Resident C's facility medical record found no care plan that addressed the resident's activity preferences, strengths, needs and wishes, or possible risk factors. No care plan that identified treatment goals related to activity participation, timetables and objectives in measurable outcomes. Resident D's facility medical record was reviewed. Resident D was originally admitted to the facility on June 16, 2017, and readmitted on September 10, 2017, with diagnoses that included urinary tract infection, schizophrenia (disorder that affects a person's ability to think and behave clearly), schizoaffective disorder (mental health condition that includes mood disorder symptoms) and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities causing significant impairment in daily life). Review of Resident D's facility, "History and Physical," (H&P), dated September 13, 2017, indicated, "This resident has the capacity to understand and make decisions." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PTDQ11 Facility ID: CA240000081 If continuation sheet 12 of 17 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 06/05/2018 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 Further review of Resident D's facility medical record found no care plan that addressed the resident's activity preferences, strengths, needs and wishes, or possible risk factors. No care plan that identified treatment goals related to activity participation, timetables and objectives in measurable outcomes. Review of the facility's job description for Activities Director, indicated, "Specific Job Functions: Maintains current documentation in the Medical Records (initial assessment, progress notes, MDS (minimum data set- an assessment), patient care plan)...Develops individual resident care plans to address activity needs in cooperation with the interdisciplinary team. All documentation in the medical record is accurate, timely and legible..." On May 24, 2018, at 4:07 p.m., an interview was conducted with the Director of Nursing (DON). The DON was asked if there was an expectation to have a care plan that addressed the resident's activities preference in the medical record. The DON stated, "Yes." The DON was informed that neither Resident C nor D had a care plan for activities. The DON was asked if the care plans would be somewhere else. The DON stated, "No, it should be in the chart." On May 29, 2018, at 12:47 p.m., a phone interview was conducted with the Activities Director (AD). The AD was asked if it was an expectation to have a care plan in the resident's record that addressed activities. The AD stated, "Yes." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PTDQ11 Facility ID: CA240000081 If continuation sheet 13 of 17 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 06/05/2018 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 Review of a facility policy titled, "Documentation, Activities," revised December 2009, indicated, "The Activity Director/Coordinator is responsible for maintain appropriate departmental documentation...1. Record keeping is a vital part of the activity programs. 2. The following records, at a minimum, are maintained by Activity Department personnel:...d. Activity progress notes. E. Individualized Activities Care Plan..."

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

F657 07/05/2018 §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 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PTDQ11 Facility ID: CA240000081 If continuation sheet 14 of 17 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 06/05/2018 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 review assessments. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to develop and implement comprehensive person-centered care plans for two of three sampled residents (Residents C and D) in a universe of 63 residents that addressed the residents individualized activity preferences and needs. This failure had the potential to negatively influence the resident's mental and psychosocial well-being. Findings: On May 24, 2018, at 2:00 p.m., an unannounced visit was made to the facility for the investigation of a complaint regarding quality of life. On May 24, 2018, Resident C's facility medical record was reviewed. Resident C was admitted to the facility on March 13, 2018, with diagnoses that included cerebral infarction (brain lesion where clusters of brain cells die with insufficient supply of blood), type 2 diabetes mellitus (condition that affects the way the body processes blood sugar), and psychoactive substance abuse (drug abuse). Review of Resident C's facility, "History and Physical," (H&P), dated May 20, 2018, indicated, "This resident has the capacity to understand and make decisions." Further review of Resident C's facility medical record found no care plan that addressed the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PTDQ11 Facility ID: CA240000081 If continuation sheet 15 of 17 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 06/05/2018 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's activity preferences, strengths, needs and wishes, or possible risk factors. No care plan that identified treatment goals related to activity participation, timetables and objectives in measurable outcomes. Resident D's facility medical record was reviewed. Resident D was originally admitted to the facility on June 16, 2017, and readmitted on September 10, 2017, with diagnoses that included urinary tract infection, schizophrenia (disorder that affects a person's ability to think and behave clearly), schizoaffective disorder (mental health condition that includes mood disorder symptoms) and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities causing significant impairment in daily life). Review of Resident D's facility, "History and Physical," (H&P), dated September 13, 2017, indicated, "This resident has the capacity to understand and make decisions." Further review of Resident D's facility medical record found no care plan that addressed the resident's activity preferences, strengths, needs and wishes, or possible risk factors. No care plan that identified treatment goals related to activity participation, timetables and objectives in measurable outcomes. Review of the facility's job description for Activities Director, indicated, "Specific Job Functions: Maintains current documentation in the Medical Records (initial assessment, progress notes, MDS (minimum data set- an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PTDQ11 Facility ID: CA240000081 If continuation sheet 16 of 17 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 06/05/2018 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 assessment), patient care plan)...Develops individual resident care plans to address activity needs in cooperation with the interdisciplinary team. All documentation in the medical record is accurate, timely and legible..." On May 24, 2018, at 4:07 p.m., an interview was conducted with the Director of Nursing (DON). The DON was asked if there was an expectation to have a care plan that addressed the resident's activities preference in the medical record. The DON stated, "Yes." The DON was informed that neither Resident C nor D had a care plan for activities. The DON was asked if the care plans would be somewhere else. The DON stated, "No, it should be in the chart." On May 29, 2018, at 12:47 p.m., a phone interview was conducted with the Activities Director (AD). The AD was asked if it was an expectation to have a care plan in the resident's record that addressed activities. The AD stated, "Yes." Review of a facility policy titled, "Documentation, Activities," revised December 2009, indicated, "The Activity Director/Coordinator is responsible for maintain appropriate departmental documentation...1. Record keeping is a vital part of the activity programs. 2. The following records, at a minimum, are maintained by Activity Department personnel:...d. Activity progress notes. E. Individualized Activities Care Plan..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PTDQ11 Facility ID: CA240000081 If continuation sheet 17 of 17