Other·August 3, 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 one complaint. Complaint number CA 00578977 Representing the CA Department of Public Health: Surveyor 37537 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Two deficiencies were issued for complaint number CA00578977

F551 SS=D Rights Exercised by Representative CFR(s): 483.10(b)(3)-(7)(i)-(iii)

F551 07/11/2018 §483.10(b)(3) In the case of a resident who has not been adjudged incompetent by the state court, the resident has the right to designate a representative, in accordance with State law and any legal surrogate so designated may exercise the resident's rights to the extent provided by state law. The same-sex spouse of a resident must be afforded treatment equal to that afforded to an opposite-sex spouse if the marriage was valid in the jurisdiction in which it was celebrated. (i) The resident representative has the right to exercise the resident's rights to the extent those rights are delegated to the representative. (ii) The resident retains the right to exercise those rights not delegated to a resident representative, including the right to revoke a delegation of rights, except as limited by State 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: A3AT11 Facility ID: CA240000081 If continuation sheet 1 of 8 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 06/11/2018 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 law. §483.10(b)(4) The facility must treat the decisions of a resident representative as the decisions of the resident to the extent required by the court or delegated by the resident, in accordance with applicable law. §483.10(b)(5) The facility shall not extend the resident representative the right to make decisions on behalf of the resident beyond the extent required by the court or delegated by the resident, in accordance with applicable law. §483.10(b)(6) If the facility has reason to believe that a resident representative is making decisions or taking actions that are not in the best interests of a resident, the facility shall report such concerns when and in the manner required under State law. §483.10(b)(7) In the case of a resident adjudged incompetent under the laws of a State by a court of competent jurisdiction, the rights of the resident devolve to and are exercised by the resident representative appointed under State law to act on the resident's behalf. The court-appointed resident representative exercises the resident's rights to the extent judged necessary by a court of competent jurisdiction, in accordance with State law. (i) In the case of a resident representative whose decision-making authority is limited by State law or court appointment, the resident retains the right to make those decisions outside the representative's authority. (ii) The resident's wishes and preferences must be considered in the exercise of rights by the representative. (iii) To the extent practicable, the resident must be provided with opportunities to participate in the care planning process. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: A3AT11 Facility ID: CA240000081 If continuation sheet 2 of 8 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 06/11/2018 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 This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure a conservator ( a person appointed by the court to manage affairs of those who can no longer make their own decisions) to support decision making for Resident A. This failure had the potential to result in medical services not to be coordinated in accordance to resident's needs due to lack of appropriate decision making capacity and lack of advocacy for Resident A. Findings: On April 12, 2018, at 9:50 a.m., an unannounced visit to the facility was conducted to investigate a complaint related to resident rights issues. On April 12, 2018, Resident A's record was reviewed. Resident A was admitted to the facility on August 25, 2016, with diagnoses which included dementia (loss of memory and other mental abilities severe enough to interfere with daily life), psychotic disorder with delusions (not able to tell what is real from what is imagined), and bipolar disorder (a disorder that causes unusual shifts in mood, energy, activity levels and ability to carry out day-to-day tasks). Resident A's History and Physical (H & P) dated August 2, 2017, indicated Resident A did not have the capacity to understand and make decisions. Resident A's MDS (minimum data set-an assessment tool) Section C (cognitive patterns), dated August 27, 2017, and indicated Resident A had a BIMS (Brief interview of mental status) score of "4". A BIMS score of 4 meant severely impaired cognitively. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: A3AT11 Facility ID: CA240000081 If continuation sheet 3 of 8 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 06/11/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr Riverside, CA 92509 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident A's "Physician Orders for Life Sustaining Treatment (POLST)," dated September 17, 2017, indicated Resident A was unable to sign the POLST due to mental status. On May 14, 2018 at 3:54 p.m., an interview with SW 1 was conducted. SW 1 stated the previous SW in the facility kept a binder with a list of residents that were referred to the office of Probate Conservator Investigator, and Resident A was not in the list. She stated she contacted the Office of Probate Conservator Investigator, and was informed that Resident A was not referred to their office. On May 23, 2018, at 8:35 a.m., the DON was interviewed, and stated obtaining public guardianship should be initiated for residents who did not have the mental capacity to make decisions and did not have family to decide on their behalf. The DON stated the facility interdisciplinary team was responsible in ensuring the process of applying for public guardianship was followed.

F660 SS=D Discharge Planning Process CFR(s): 483.21(c)(1)(i)-(ix)

F660 07/11/2018 §483.21(c)(1) Discharge Planning Process The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to postdischarge care, and the reduction of factors leading to preventable readmissions. The facility's discharge planning process must be consistent with the discharge rights set forth at 483.15(b) as applicable and(i) Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: A3AT11 Facility ID: CA240000081 If continuation sheet 4 of 8 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 06/11/2018 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. (ii) Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes. (iii) Involve the interdisciplinary team, as defined by §483.21(b)(2)(ii), in the ongoing process of developing the discharge plan. (iv) Consider caregiver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs. (v) Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan. (vi) Address the resident's goals of care and treatment preferences. (vii) Document that a resident has been asked about their interest in receiving information regarding returning to the community. (A) If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose. (B) Facilities must update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities. (C) If discharge to the community is determined to not be feasible, the facility must document who made the determination and why. (viii) For residents who are transferred to another SNF or who are discharged to a HHA, IRF, or LTCH, assist residents and their resident representatives in selecting a postacute care provider by using data that includes, but is not limited to SNF, HHA, IRF, or LTCH standardized patient assessment data, data on quality measures, and data on resource use to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: A3AT11 Facility ID: CA240000081 If continuation sheet 5 of 8 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 06/11/2018 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 extent the data is available. The facility must ensure that the post-acute care standardized patient assessment data, data on quality measures, and data on resource use is relevant and applicable to the resident's goals of care and treatment preferences. (ix) Document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident's representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure a safe discharge process, when Resident A who had dementia (loss of memory and other mental abilities severe enough to interfere with daily life) was discharged to a room and board (provides lodging, utilities, and food for a fee) instead of a Board and Care facility (living situation for seniors and people with disabilities who need help with meal preparation, medication monitoring, and personal care). This failure resulted in Resident A to experience an unsafe transition to the community. Findings: On April 12, 2018, at 9:50 a.m., an unannounced visit to the facility was conducted to investigate a complaint related to resident rights issues. On April 12, 2018, Resident A's facility record was reviewed. Resident A was admitted to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: A3AT11 Facility ID: CA240000081 If continuation sheet 6 of 8 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 06/11/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr Riverside, CA 92509 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility on August 25, 2016, with diagnoses that included dementia (loss of memory and other mental abilities severe enough to interfere with daily life), psychotic disorder with delusions (not able to tell what is real from what is imagined), and bipolar disorder (a disorder that causes unusual shifts in mood, energy, activity levels and ability to carry out day-to-day tasks). Resident A's History and Physical dated August 2, 2017, indicated Resident A did not have a capacity to understand and make decisions. Resident A's notice of proposed transfer discharge dated November 1, 2017, did not indicate the reason for discharge. The document did not indicate who needed to be contacted to appeal discharge. Resident A's "Physician's Report for Residential Care facilities for the Elderly (RCFE)," dated November 1, 2017, indicated the following: 1. Primary Diagnosis- Essential hypertension (high blood pressure): a. Treatment/Medication: Lisinopril (cardiac medication) 40 mg tab two times a day, b. Can patient manage own treatment: No, c. What type of medical supervision is needed: Medication management; 2. Other Conditions: Generalized weakness: Medical Supervision needed: Limited Assistance to ADL (Activity of Daily Living); 3. Capacity for Self-Care: Able to Bathe self: No, only needs supervision; and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: A3AT11 Facility ID: CA240000081 If continuation sheet 7 of 8 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 06/11/2018 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 4. Medication Management: Able to Administer Own Prescription Medications: NO, and Able to store own medication: No. Resident A's physician discharge order dated November 1, 2017, stated: "May discharge resident to board and care (name of facility) address phone and fax numbers." Resident A's discharged note dated November 2, 2017, at 12:59 p.m., indicated, " (RCFE) was discussed... was signed by Bioethics Committee. Resident (Resident A) was discharged to (name of the residence) and left the facility @ (at) 12:30 p.m. with proper documents and medications." On April 9, 2018, at 12:30 p.m., an interview was conducted with the Director of Nursing (DON). She stated resident with dementia should be discharge to a licensed facility. The DON further stated, "It should be safe." On April 10, 2018, at 12:50 p.m., Social Worker (SW) 2 from Adult Protective Services (APS) was interviewed. SW 2 stated Resident A was discharged to a room and board, and not to a board and care facility. She further stated the residence (room and board) and Resident A's case was being investigated. On April 12, 2018, at 10:45 a.m., Licensing Evaluator (LE) from the office of Community Licensing was interviewed. LE stated Resident A has board and care needs but was transferred to an unlicensed facility. LE stated the residence was a room and board, not a board and care facility. She stated Resident A required care and supervision, and was recommended to be moved to another facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: A3AT11 Facility ID: CA240000081 If continuation sheet 8 of 8