Other·August 22, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a first revisit survey conducted on May 29 and 30, 2018, following a recertification survey from April 17, 2018. Representing the Department: Surveyor 36684, HFEN; and Surveyor 33841, HFES. Census: 62 Residents. Sample size: 19 Residents.

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

F578 06/14/2018 §483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. §483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate. §483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the 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: 3H3Z12 Facility ID: CA240000081 If continuation sheet 1 of 12 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 05/30/2018 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 option, formulate an advance directive. (ii) This includes a written description of the facility's policies to implement advance directives and applicable State law. (iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. (iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law. (v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed, for one of three sampled residents (Resident 217), to ensure the Physician Orders for Life-Sustaining Treatment (POLST- a form that documents a resident's treatment and wishes in the event of a medical emergency) was signed by the physician for accuracy and validation. This failure had the potential to provide inappropriate treatment and services to Resident 217 in the event of a medical emergency. Findings: On May 29, 2018, at 11:06 a.m., Resident 217's record was reviewed with the Social Service Director (SSD). Resident 217 was admitted to the facility on February 28, 2018. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z12 Facility ID: CA240000081 If continuation sheet 2 of 12 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 05/30/2018 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 POLST, located in Resident 217's record, indicated, "...Attempt Resuscitation/CPR (cardiopulmonary resuscitation- emergency procedure that combines chest compressions often with artificial ventilation)...Full treatmentprimary goal of prolonging life by all medically effective means..." The POLST was signed and dated by Resident 217 on March 7, 2018. The POLST Signature of Physician/Nurse Practitioner/Physician Assistant section was blank. The POLST did not also indicate the Preparer's Name. Included in the POLST was a Direction for Health Care Provider which indicated, "...POLST must be completed by a health care provider based on patient preferences and medical indication...To be valid a POLST form must be signed by (1) a physician, or by a nurse practitioner or a physcian assistant acting under the supervision of a physician and within the scope of practice authorized by law... There was no documented evidence Resident 217's POLST was signed and validated for accuracy by Resident 217's physician. In addition, there was no documented evidence Resident 217's POLST was completed and prepared by a licensed facility staff member. In a concurrent interview, the SSD stated Resident 217's POLST was incomplete. The SSD stated Resident 217's POLST should have been signed by the licensed nurse who had prepared and discussed the POLST with the resident upon admission. The SSD stated Resident 217's physician should have signed the POLST. The SSD stated she did not check Resident 217's POLST for accuracy and completeness when she did a review on Resident 217's record. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z12 Facility ID: CA240000081 If continuation sheet 3 of 12 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 05/30/2018 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 policy and procedure titled, "...SKILLED NURSING FACILITIES... Physician orders for Life Sustaining Treatment (POLST)," dated October 20, 2017, was reviewed. The policy indicated, "...The POLST form...Is legally sufficient and recognized as a physician order... While a health care provider such as nurse or social worker can explain the POLST form to the resident and or the resident's legally recognized health care decisionmaker, the physician is responsible for discussing the efficacy or appropriateness of the treatment options with the resident... Once the POLST form is completed, it must be signed by the resident, or if the resident lacks decisionmaking capacity the resident's legally health care decisionmaker, AND the attending physician..."

F842 SS=D Resident Records - Identifiable Information CFR(s): 483.20(f)(5), 483.70(i)(1)-(5)

F842 06/14/2018 §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that areFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z12 Facility ID: CA240000081 If continuation sheet 4 of 12 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 05/30/2018 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 (i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is(i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for(i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain(i) Sufficient information to identify the resident; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z12 Facility ID: CA240000081 If continuation sheet 5 of 12 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 05/30/2018 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 (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to ensure an accurate documentation was maintained in accordance to professional standard for two (Resident 36 and 41) of five sampled residents, when: 1. For Resident 36, medication Florastor (probiotic-dietary supplement) was not administered timely but signed as administered at 7 a.m.; 2. For Resident 41, medications Omeprazole ( prevents the production of acid in the stomach) and Synthroid (thyroid hormone),were documented as refused but interview statement indicated medications were not refused by the resident; and 3. For Resident 41, medication Ferrous sulfate was not given at 7:30 a.m., but was signed as administered. These failures had the potential to negatively impact the care for Resident 36 and 41. Findings: 1. During medication pass observation on May 29, 2018, at 8:35 a.m., Licensed Vocational Nurse (LVN) 2 prepared stool softener 100 mg FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z12 Facility ID: CA240000081 If continuation sheet 6 of 12 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 05/30/2018 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 (milligram) (1 tablet), Multivitamins with mineral tablet (1 tablet), Vitamin C 500 mg (1 tablet) Benztropine (treat the symptoms of Parkinson ' s disease) 1 mg (1 tablet), Buspar (treat anxiety) 10 mg (1 tablet), Depakote (prevent seizures) 500 mg (1 tablet), and Seroquel ( used to treat bipolar disorder) 100 mg (1 tablet) LVN 2 acknowledged there were seven (7) medications in the cup prepared for Resident 36. Resident 36's record was reviewed. Resident 36 was readmitted to the facility on May 22, 2018, with diagnoses which included epilepsy (disorder that causes seizures). Resident 36's physician orders dated May 22, 2018, were reviewed and indicated the following: a. Vitamin C 500 mg tablet give 1 tab po (by mouth) BID (two times a day) for supplement; b. Depakote DR 500 mg tablet give 1 tab BID for poor impulse control m/b (manifested by) easily gets agitated, screaming, and yelling. ICOD (informed consent by) MD (medical doctor) from RR (responsible party) and verified by two license staff; c. Seroquel 100 mg 1 tablet PO BID for Schizophrenia (mental disorder that is characterized by disturbances in thought) M/B aggressive behavior, striking out staff. ICOB by MD verified by two license staff; d. Buspirone 10 mg 1 tablet PO TID (three times a day) for anxiety M/B being restlessness and increase irritability. ICOB MD from RR and verified by 2 licensed staff; e. Florastor 250 mg capsule Give 1 cap PO QD for GI (gastrointestinal) prophylaxis; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z12 Facility ID: CA240000081 If continuation sheet 7 of 12 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 05/30/2018 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 f. Colace 100 mg capsule give 1 cap PO QD for bowel management **Hold for loose stools**; g. Multivitamins with mineral tablet give 1 tab PO QD for supplement; and h. Benztropine MES (mesylate) 1 mg tablet give 1 tab PO BID for EPS (extrapyramidal symptoms- drug-induced movement diorders) Resident 36's Medication Administration Record (MAR) dated May 1 to 29, 2018, indicated Vitamin C, Depakote, Benztropine, Seroquel, Buspirone, Colace, Multivitamin with mineral, and Florastor were documented as administered. The seven documented medications administered in the MAR for May 29, 2018, were the same medications observed during medication pass at 8:35 a.m., except for Florastor. On May 29, 2018, at 11:50 a.m., LVN 2 was requested to show medication Florastor ordered for Resident 36. LVN 2 went through the bubble pack of medication, and liquid medications in the medication cart, but was not able to show the medication Florastor. (This medication was signed by LVN as administered at 7 a.m.) On May 29, 2018, at 11:29 a.m., the Director of Nursing (DON) was interviewed. She stated medications should be given according to the physician's order. The DON stated if medications were not given then the nurses were expected to document. On May 30, 2018, at 8:20 a.m., Resident 36's MAR was reviewed with LVN 2. LVN 2 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z12 Facility ID: CA240000081 If continuation sheet 8 of 12 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 05/30/2018 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 acknowledged Florastor was signed as administered at 7 a.m. She stated she did not give the medication the morning of May 29, 2018, and had to ask another nurse regarding the medication. LVN 2 stated she should not have not sign any medication she did not give during the specified time. 2. During medication pass observation on May 29, 2018, at 8:48 a.m., LVN 2 prepared medications for Resident 41 which included: Vitamin C 500 mg 1 tablet, Multivitamin with mineral 1 tablet, Aspir-low enteric coated 81 mg 1 tablet, Omeprazole 1 capsule 20 mg, Levothyroxine 100 mg 1 tablet, Divalproex 250 mg 2 tablets. LVN 2 acknowledged seven (7) medication in the cup prepared for Resident 41. Resident 41's record was reviewed. Resident 41 was readmitted to the facility on November 16, 2015, with diagnoses which included gastrointestinal hemorrhage. Resident 41's physician orders were reviewed and indicated the following: a. Vitamin C 500 mg PO (by mouth) QD (every day) supplement (to enhance iron absorption); b. Multivitamin with mineral PO QD supplement; c. Ferrous Sulfate 325 mg tablet PO TID (three times a day) iron supplement; d. Synthroid (Levothroxine) 100 mcg (microgram) tablet PO QAM (every morning) (Take with empty stomach 30 minutes prior to breakfast) hypothyroid; e. Divalproex Sodium (Depakote) 500 mg PO BID for poor impulse control manifested by becoming easily agitated; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z12 Facility ID: CA240000081 If continuation sheet 9 of 12 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 05/30/2018 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 f. Aspirin EC 81 mg tablet PO QD for CVA prophylaxis;and g. Omeprazole DR 20 mg by mouth before breakfast, dinner for GERD (gastro esophageal reflux diease). Resident 41's Medication Administration Record (MAR) dated May 1 to 29, 2018, indicated Vitamin C (7 a.m.), Multivitamin with mineral (7 a.m.), Ferrous sulfate (7:30 a.m.), aspirin (7 a.m.), Omeprazole (6:30 a.m.), Synthroid (6:30 a.m.), and Depakote (7:30 a.m.), were all signed as administered. Resident 41's Omeprazole and Synthroid were ordered by the physician to be administered before meals but was given during the medication pass observation at 8:48 a.m. Resident 41's Ferrous sulfate was not included in the medication prepared by LVN 2 during the medication pass observation at 8:48 a.m. On May 29, 2018, at 11:50 a.m., LVN 2 was interviewed regarding Resident 41's Ferrous sulfate, and she stated Ferrous sulfate was not suppose to be given until noon. On May 30, 2018, at 8:20 a.m., Resident 41's MAR was reviewed with LVN 2 regarding Resident 41's Ferrous sulfate. LVN 2 stated Resident 41's Ferrous sulfate was supposed to be given three times a day (7:30 a.m., 11:30 a.m., and 4:30 p.m.). She stated she gave Resident 41 the dose for 11:30 a.m., not the 7:30 a.m. She stated she should have not signed the medication as administered. LVN 2 stated she had not given the medications scheduled before breakfast (6:30 a.m.) because she needed to go to the dining area the morning of May 29, 2018, to assist with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z12 Facility ID: CA240000081 If continuation sheet 10 of 12 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 05/30/2018 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 breakfast for the residents. She stated she would call the physician to report the medications which were not given on time. On May 30, 2018, Resident 41's nurses notes were reviewed and indicated the following: a. May 29, 2018, at 12:06 p.m., "Levothyroxine and Omeprazole dr. (sic) given after breakfast. MD notified. No new orders noted. Will continue to monitor resident; and b. May 29, 2018, at 12:32 p.m., addendum,"Resident refused med. when first offered before breakfast. MD aware, given after breakfast. No adverse side effects noted." On May 30, 2018, at 11: 10 a.m., LVN 2 was interviewed regarding Resident 41's nurses notes which was not reflective of the statement she provided during the interview at 8:20 a.m., regarding the medications Levothyroxine and Omeprazole. She stated she called the MD on May 29, 2018, regarding the late administration of medications. LVN 2 stated she was at the dining room for breakfast on May 29, 2018, and unable to pass medications not until after breakfast. She stated medications (Omeprazole and Synthroid) were not offered and refused by Resident 41. The facility policy and procedure was reviewed. The policy titled, "Administering Medications," revised December 2012, indicated the following, "Policy Statement Medications shall be administered in a safe and timely manner, and as prescribed...Medications must be administered in accordance with the orders, including any required time frame...If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z12 Facility ID: CA240000081 If continuation sheet 11 of 12 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 05/30/2018 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 space provided for that drug and dose..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H3Z12 Facility ID: CA240000081 If continuation sheet 12 of 12