Other·April 18, 2019

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 re-certification survey conducted from Ocotober 29, 2018 to November 1, 2018. Representing the California Department of Public Health: Surveyor 39503, HFEN; Surveyor 36684; HFEN; and Surveyor 37537, HFEN; The facility census was 68 residents. One Facility Reported Incident CA00608653 was included during the recertification survey, it was unsubstantiated.

F623 SS=E Notice Requirements Before Transfer/Discharge CFR(s): 483.15(c)(3)-(6)(8)

F623 12/01/2018 §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State LongTerm Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in 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: OC6811 Facility ID: CA240000081 If continuation sheet 1 of 40 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 11/01/2018 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 paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OC6811 Facility ID: CA240000081 If continuation sheet 2 of 40 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 11/01/2018 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 Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l). This REQUIREMENT is not met as evidenced by: Based on interview and record review, for four of four residents reviewed for hospitalization (Residents 167, 30, 57, and 62), the facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OC6811 Facility ID: CA240000081 If continuation sheet 3 of 40 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 11/01/2018 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 failed to provide a documented evidence a notice before transfer was provided to the resident and/or resident representative (RR), and the reason for the move in writing, and in a language and manner they understand, that specifies: - The reason, effective date, and location for the transfer or discharge; - A statement of the resident's appeal rights; - Name, address, and telephone number of the ombudsman; and - Address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities and individuals with mental disorders. In addition, the facility failed to provide a copy of notice of transfer to the Ombudsman. This facility failure may result to the resident and/or RR, not to be aware of their rights and privileges accorded to nursing facility's residents, who were transferred to the hospital for emergency purposes or for therapeutic leave of absence, and for the Ombudsman to intervene on a timely manner on behalf of the residents, if they should need assistance after they are transferred or discharged. Findings: 1. On November 1, 2018, Resident 167's record was reviewed. Resident 167 was admitted to the facility on May 3, 2018. The physician's order dated May 24, 2018, indicated Resident 167 was to be transferred to (name of hospital) for evaluation related to positive x-ray result. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OC6811 Facility ID: CA240000081 If continuation sheet 4 of 40 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 11/01/2018 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 nursing progress notes dated May 24, 2018, indicated Resident 167's chest x-ray result was positive for bilateral diffuse course interstitial opacities (type of lung disease). The nursing progress notes further indicated Resident 167's physician gave an order for the resident to be transferred to an acute hospital. There was no documented evidence a copy of notice of transfer was provided to the Ombudsman when Resident 167 was transferred to the acute hospital on May 24, 2018. On November 1, 2018, at 2:59 p.m., Resident 167's record was reviewed with the Social Service Director (SSD). The SSD stated she did not notify and/or provide a copy of notice before transfer to the Ombudsman, on the facility initiated transfer of Resident 167 to the acute hospital on May 24, 2018. 2. On November 1, 2018, Resident 30's record was reviewed. Resident 30 was admitted to the facility on October 8, 1991, with diagnoses that included bipolar disorder (a mental disorder characterized by mood swings). Resident 30 did not have the capacity to understand and make decisions. The resident was under the Public Guardian (employed to act as a guardian /conservator when no private person or agency is available or able to act in that capacity). Resident 30's physician's order, dated June 28, 2018, indicated Resident 30 was sent to acute hospital for further evaluation due to her increase agitation and yelling to the staff. There was no documented evidence a written notice of transfer was given to the resident or resident representative (RR), nor a copy of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OC6811 Facility ID: CA240000081 If continuation sheet 5 of 40 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 11/01/2018 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 written notice of transfer was given to the Ombudsman when Resident 30 was transferred to the hospital on June 28, 2018. 3. On October 30, 2018, Resident 57's record was reviewed. Resident 57 was admitted to the facility on May 22, 2015, with diagnoses that included gastro-esophageal reflux disease (a digestive disease in which the stomach acid or bile irritates the esophagus - food pipe lining). Resident 57 did not have the capacity to understand and make decisions. The resident was under the Public Guardian (employed to act as a guardian /conservator when no private person or agency is available or able to act in that capacity). Resident 57's progress notes, dated June 8, 2018, indicated Resident 57 was sent to the acute hospital for abdominal pain. The resident was readmitted back to the facility. Resident 57's physician's order, dated July 13, 2018, indicated Resident 57 was transferred to the acute hospital for evaluation and treatment of abdominal pain. There was no documented evidence a written notice of transfer was given to the resident or RR, nor a copy of the written notice of transfer was given to the Ombudsman when Resident 57 was transferred to the hospital on June 8, 2018, and July 13, 2018. 4. On October 30, 2018, Resident 62's record was reviewed. Resident 62 was admitted to the facility on July 6, 2017, with diagnoses that included psychosis (a mental disorder characterized by a disconnection from reality), dementia (loss of memory), and retention of urine. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OC6811 Facility ID: CA240000081 If continuation sheet 6 of 40 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 11/01/2018 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 62 did not have the capacity to understand and make decisions. Resident 62's family member was the resident representative (RR). Resident 62's physician's order, dated June 30, 2018, indicated Resident 62 was transferred to the acute hospital for weight loss. Resident 62 was readmitted back to the facility. Resident 62's physician's order, dated August 11, 2018, indicated Resident 62 was sent to emergency room for acute renal failure (kidney functions were not working) and abnormal laboratory test results. There was no documented evidence a written notice of transfer was given to the resident or RR, nor a copy of the written notice of transfer was given to the Ombudsman when Resident 62 was transferred to the hospital on June 30, 2018, and August 11, 2018. On October 30, 2018, at 3:10 p.m., a concurrent record review and interview was conducted with the Director of Nursing (DON). The DON stated a written notice of transfer was given only to the resident or RR on planned discharges. The DON stated she was not aware a written notice of transfer should be given to the resident or RR when the resident was hospitalized. The DON stated there was no documented evidence a written notice of transfer was given to: - Resident 30 or RR when transferred to the hospital on June 28, 2018; - Resident 57 or RR when transferred to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OC6811 Facility ID: CA240000081 If continuation sheet 7 of 40 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 11/01/2018 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 hospital on June 8, 2018, and July 13, 2018; and - Resident 62 or RR when transferred to the hospital on June 30, 2018, and August 11, 2018. On October 31, 2018, at 10:01 a.m., a concurrent record review and interview was conducted with the Social Services Director (SSD). The SSD stated the nurses were responsible in providing a written notice of transfer to the resident or RR upon discharge and she was responsible in providing the Ombudsman a copy of the written notice of transfer when a resident was discharged from the facility. The SSD stated she only provided copy of the written notice of transfer to the Ombudsman when the resident had a planned discharge. The SSD stated she was not aware a copy of the written notice of transfer should be given to the Ombudsman for residents that were transferred to the hospital. The SSD stated there was no documented evidence a copy of the written notice of transfer was given to the Ombudsman when: - Resident 30 was transferred to the hospital on June 28, 2018; - Resident 57 was transferred to the hospital on June 8, 2018, and July 13, 2018; and - Resident 62 was transferred to the hospital on June 30, 2018, and August 11, 2018. The facility's policy and procedure titled, "Transfer and Discharge Notice," dated October 17, 2018, indicated, "...Except as FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OC6811 Facility ID: CA240000081 If continuation sheet 8 of 40 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 11/01/2018 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 specified below, a resident, and/or his or her representative (sponsor) will be given a thirty (30) day advance notice of an impending transfer or discharge from our facility ...an immediate transfer or discharge is required by the resident's urgent medical needs ...The resident and/or representative (sponsor) will be provided with the following information: a. The reason for the transfer or discharge; b. The effective date of the transfer or discharge; c. The location to which the resident is being transferred or discharge; d. The name, address, and telephone number of the state long-term care ombudsman; e. The name, address, and telephone number of each individual or agency responsible for the protection and advocacy of mentally ill or developmental disabled individuals (as applies); and f. The name, address, and telephone number of the state health department agency that has been designed to handle appeals of transfers and discharge notices..." The facility's policy for "Transfer and Discharge Notice," did not indicated the federal requirement of notifying the Ombudsman for any facility initiated transfer of the residents.

F676 SS=D Activities Daily Living (ADLs)/Mntn Abilities CFR(s): 483.24(a)(1)(b)(1)-(5)(i)-(iii) FORM CMS-2567(02-99) Previous Versions Obsolete

F676 Event ID: OC6811 12/01/2018 Facility ID: CA240000081 If continuation sheet 9 of 40 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 11/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr Riverside, CA 92509 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.24(a) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that: §483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section ... §483.24(b) Activities of daily living. The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living: §483.24(b)(1) Hygiene -bathing, dressing, grooming, and oral care, §483.24(b)(2) Mobility-transfer and ambulation, including walking, §483.24(b)(3) Elimination-toileting, §483.24(b)(4) Dining-eating, including meals and snacks, §483.24(b)(5) Communication, including (i) Speech, (ii) Language, (iii) Other functional communication systems. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide necessary FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OC6811 Facility ID: CA240000081 If continuation sheet 10 of 40 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 11/01/2018 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 care and services needed by the resident to perform ADL (Activity of Daily Living) for one of one resident (Resident 30) reviewed, when Resident 30 was not provided a communication board to help with the resident's aphasia (a language disorder that affects a person's ability to communicate). This failure could result to Resident 30 not able to communicate her needs and concerns. Findings: On October 29, 2018, at 9:41 a.m., Resident 30 was observed sitting on her bed. When the resident was asked of her name, Resident 30 put her hand up and gestured to wait. Resident 30 pulled a piece of paper and pen from her purse and wrote her full name. Resident 30 pointed on her closet, appeared frustrated, and gestured that she wanted it opened. On November 1, 2018, Resident 30's record was reviewed. Resident 30 was admitted to the facility on October 8, 1991, with diagnoses that included aphasia. Resident 30 did not have the capacity to understand and make decisions. Resident 30's care plan dated July 15, 2018, indicated, "PROBLEM/NEEDS Communication problem r/t (related to) Aphasia...GOALS Will be able to communicate needs daily...APPROACHES/PLAN...Explore use of assistive device eg. (example given) communication board..." On November 1, 2018, at 10:34 a.m., an observation and interview was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 was approached by Resident 30 and pointing on her purse and put up her hands showing her two FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OC6811 Facility ID: CA240000081 If continuation sheet 11 of 40 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 11/01/2018 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 fingers. LVN 1 asked several questions to the resident on what Resident 30 was trying to communicate regarding her purse. LVN 1 stated Resident 30 was aphasic and the resident communicate through gesture. LVN 1 stated Resident 30 was able to respond to simple questions by nodding her head with a "yes" or shaking her head with a "no." When Resident 30 wanted to communicate something to her she tried to guess what the resident was saying based on what the resident point out or through her gesture. LVN 1 stated Resident 30 did not have a communication board to use. LVN 1 stated Resident 30 should have the communication board, it would help the resident communicate her needs and concerns better. On November 1, 2018, at 10:49 a.m., Certified Nursing Assistant (CNA) 1 was interviewed. CNA 1 stated Resident 30's means of communication was by signs and gestures. CNA 1 stated Resident 30 was able to use paper and pen because the resident was able to draw a heart before and gave it to her. CNA 1 stated Resident 30 did not have a communication board to use. CNA 1 stated Resident 30 should have the communication board, it would help the resident communicate her needs and concerns better. On November 1, 2018, at 11:18 a.m., the Director of Nursing (DON) was interviewed. The DON stated any staff should be able to provide Resident 30 a communication board to use. The DON stated Resident 30 should have the communication board as indicated on the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OC6811 Facility ID: CA240000081 If continuation sheet 12 of 40 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 11/01/2018 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 care plan to assist in communicating the resident's daily needs. The facility's policy and procedure titled, "Quality of Life - Accomodations of Needs," dated October 17, 2018, indicated, "...The resident's individual needs and preferences shall be accomodated to the extent possible...Staff shall interact with the residents in a way that accomodate the physical or sensory limitations of the residents, promotes communication..."

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

F684 12/01/2018 § 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. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure for one of 18 residents reviewed (Resident 62) received treatment and care in accordance with professional standards of practice when, Resident 62 did not have a wheelchair foot rest that would provide support and proper positioning for the resident. This failure may result to poor posture and development of potential contracture (a condition of shortening and hardening of muscles, tendons, or other tissue often leading FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OC6811 Facility ID: CA240000081 If continuation sheet 13 of 40 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 11/01/2018 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 to deformity and rigidity of joints). Findings, On October 29, 2018, at 10:50 a.m., Resident 62 was observed in the dining room, sitting in a manual tilt and space wheelchair (a specialized wheelchair that allows the whole chair to tilt backward). Resident 62's wheelchair was reclined with no footrests. Resident 60's both lower extremities were dangling in the air. Resident 16 was awake but was not able to appropriately respond to the interview questions. At 11:45 a.m., Resident 62 was still in the dining room sitting in his manual tilt and space wheelchair. Resident 62's wheelchair was reclined with no footrests. Resident 60's both lower extremities were dangling in the air. On October 30, 2018, at 8:34 a.m., Resident 62 was observed in the TV (television) area, sitting in his manual tilt and space wheelchair. Resident 62's wheelchair was reclined with no footrests. Resident 60's both lower extremities were dangling in the air, feet were crossed and pointing down. On October 30, 2018, Resident 62's record was reviewed. Resident 62 was admitted to the facility on July 6, 2017. Resident 62 did not have the capacity to understand and make decisions. Resident 62's assessment for the use of manual tilt and space wheelchair dated February 26, 2018, indicated, "...(name of resident) was assessed for a seating and mobility evaluation ...(name of resident) now FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OC6811 Facility ID: CA240000081 If continuation sheet 14 of 40 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 11/01/2018 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 requires the use of a manual tilt space wheelchair to meet the needs of his deteriorating medical condition and address his permanent mobility impairment ...Elevating...legrest...Elevating footrest are necessary as (name of the resident) has compromised circulation...and must elevate the legs throughout the day ...Angle Adjustable Footplates...it is essential to provide support and positioning of the feet ...Footplate Heel Loops...required to help maintain proper alignment when (name of the resident) is seated..." On October 29, 2018, at 11:45 a.m., a concurrent observation and interview was conducted with the Restorative Nurse Assistant (RNA). The RNA stated Resident 62 did not have a wheelchair footrests and the resident's feet was dangling in the air. The RNA stated Resident 62's wheelchair footrests were broken since Saturday (October 27, 2018). RNA stated Resident 62 had the special order wheelchair and a specific footrests for the wheelchair was needed to be ordered. The RNA stated Resident 62 should have the wheelchair footrests to provide support and proper positioning of the resident. On October 30, 2018, at 9:43 a.m., the Certified Occupational Therapy Assistant (COTA) was interviewed. The COTA stated Resident 62 was on a manual tilt and space wheelchair. The OT stated she was informed today of the issue on Resident 62's wheelchair footrests not being available. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OC6811 Facility ID: CA240000081 If continuation sheet 15 of 40 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 11/01/2018 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 COTA stated when Resident 62's wheelchair footrests were not available, the resident should have been placed on another wheelchair with the footrests. The COTA stated Resident 62 should have the wheelchair footrests at all times when he sit in his wheelchair. The COTA stated the wheelchair footrest was necessary for Resident 62's proper positioning and support when he is in the wheelchair. On October 30, 2018, at 9:53 a.m., the Director of Nursing (DON) was interviewed. The DON stated Resident 62 was mostly in his wheelchair during the day and he would be in bed after lunch to rest. The DON stated Resident 62 needed the wheelchair footrests for support and proper positioning. The facility's policy and procedure titled, "POSITIONING," dated October 17, 2018, indicated, "...Positioning a resident in a wheelchair...Adjust the leg rests to support resident's feet...Keep the resident as straight and comfortable as possible while in the wheelchair..."

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 12/01/2018 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OC6811 Facility ID: CA240000081 If continuation sheet 16 of 40 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 11/01/2018 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 observation, interview, and record review, for one of five residents (Resident 40) reviewed for falls the facility failed to provide an environment that is free from accident hazards. This failure had the potential for Resident 40 to have further risk of falls when Resident 40 did not have a bedside floor mat as ordered by the physician. Findings: On October 30, 2018, Resident 40's record was reviewed. Resident 40 was admitted to the facility on March 7, 2018, with diagnoses that included encephalopathy (a disease that affects the function of the brain) and abnormalities of the gait and mobility (a deviation from normal walking). Resident 40's physician's order dated June 13, 2018, indicated Resident 40 may have a low bed and mat at bedside. Resident 40's care plan for Fall Risk, dated June 6, 2018, indicated, " At risk for falls r/t ...Hx of multiple falls... Wandering...Balance Problem...Poor Safety..." GOALS "Will reduce the risk for falls for 90 days." APPROACHES/PLAN "Mat on floor as ordered..." Resident 40's Fall Risk Assessment was dated on September 14, 2018. The fall risk assessment indicated: "...balance problem while standing and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OC6811 Facility ID: CA240000081 If continuation sheet 17 of 40 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 11/01/2018 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 balance problem while walking..." The grand total for the fall risk assessment score was 15. On October 31, 2018, at 3:15 p.m., a concurrent observation and record review was conducted with Licensed Vocational Nurse (LVN 2) . Resident 40 did not have a mat on the floor by his bedside. LVN 2 stated Resident 40 did not have a mat next to his bed, "it should be there." On November 1, 2018 at 11:30 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated the score of 15 for fall risk was 15. The DON stated the score of 15 for fall risk was high. The DON stated Resident 40 should have the floor mat as indicated on the resident's care plan and physician's orders.

F700 SS=D Bedrails CFR(s): 483.25(n)(1)-(4)

F700 12/01/2018 §483.25(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. §483.25(n)(1) Assess the resident for risk of entrapment from bed rails prior to installation. §483.25(n)(2) Review the risks and benefits of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OC6811 Facility ID: CA240000081 If continuation sheet 18 of 40 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 11/01/2018 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 bed rails with the resident or resident representative and obtain informed consent prior to installation. §483.25(n)(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight. §483.25(n)(4) Follow the manufacturers' recommendations and specifications for installing and maintaining bed rails. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure for one of one resident (Resident 36) reviewed, an assessment for the risk of entrapment prior to the use of bed rails was conducted prior to use. This failure had the potential for the resident to experience entrapment, accidents, and avoidable injuries. Findings: On October 29, 2018, at 9:30 a.m., an observation and an interview was conducted with Certified Nursing Assistant (CNA) 2. Resident 36 was observed in bed with bilateral full side rails up. Resident 36 was awake and did not respond when spoken to. CNA 2 stated Resident 36 was non-verbal and he was fully dependent with his ADLs (Activities of Daily Living) including bed mobility. On November 11, 2018, at 9:47 a.m., Resident 36's record was reviewed with the Director of Nursing (DON). Resident 36 was re-admitted to the facility on August 31, 2018, with diagnoses that included muscle weakness and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OC6811 Facility ID: CA240000081 If continuation sheet 19 of 40 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 11/01/2018 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 Alzheimer's disease ( progressive memory loss). A hospice (specialized care for the sick especially the terminally ill) physicina's order dated October 2, 2018 indicated an order for bilateral side rails up for patient safety and to prevent resident from sliding off the low air loss mattress (special air bed used for skin management). The hospice document titled, "Fall Risk Assessment," dated October 2, 2018, indicated, "Patient has diagnosis of Alzheimer's Disease (progressive memory loss), and confused at times, with balance problems and is bed bound at all times. Patient is assessed and is identified to be high risk for falls..." There was no documented evidence an assessment for the risk of entrapment was conducted prior to the use of bed rails on October 2, 2018. In a concurent interview, the DON stated Resident 36 used the full bilateral bed rails since it was ordered by hospice on October 2, 2018. The DON stated the facility should have conducted an assessment for the risk of entrapment prior to the use of the full bilateral bed rails in bed. The DON stated this was not done. The facility's policy and procedure titled, "Bed Safety, " dated October 17, 2018, was reviewed. The policy indicated, "...To try to prevent deaths/injuries from the beds and related equipment (including frame, mattress, side rails...)the facility shall promote the following approaches... Review the gaps within the bed system are FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OC6811 Facility ID: CA240000081 If continuation sheet 20 of 40 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 11/01/2018 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 within the dimesions established by the FDA (Food and Drug Administration)...Note: The review shall consider situations that could be caused by the resident's weight, movement or bed position... Ensure the bed rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit... If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the Attending Physician, and input from the resident and/or legal representative... Side rails may be used if assessment and consultation with the Attending Physician has determined that they are needed to help manage a medical symptom or condtion, or to help the resident reposition or move in bed and transfer, and no other reasonable alternatives can be identified..."

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

F757 12/01/2018 §483.45(d) Unnecessary Drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used§483.45(d)(1) In excessive dose (including duplicate drug therapy); or §483.45(d)(2) For excessive duration; or §483.45(d)(3) Without adequate monitoring; or §483.45(d)(4) Without adequate indications for its use; or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OC6811 Facility ID: CA240000081 If continuation sheet 21 of 40 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 11/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr Riverside, CA 92509 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or §483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. This REQUIREMENT is not met as evidenced by: 2. On October 31, 2018, Resident 2's record was reviewed. Resident 2 was admitted to the facility on March 29, 2017, with diagnoses that included rheumatoid arthritis (an inflammatory disorder affecting the joints) and osteoarthritis (joint pain and stiffness). Resident 2 did not have the capacity to understand and make decisions. Resident 2's physician's order indicated: - Percocet (narcotic pain medication) 10-325 milligram (mg) give 1 tablet by mouth every four hours as needed for severe pain 7-10 (pain level 0 - no pain to 10 - worst possible pain), was ordered on July 16, 2018; - Tylenol (non-narcotic pain medication) 325 mg give 2 tablet by mouth every four hours as needed for mild pain 1-3, was ordered on July 18, 2018; - Robaxin 500 mg tablet by mouth every eight hours as needed for muscle relaxant, was ordered on October 7, 2018; - Lidocaine 5% patch (pain medication) apply one patch transdermal (application of the medication through the skin) once a day as needed for pain, was ordered on October 7, 2018; and - Voltaren 1% gel (pain medication) apply FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OC6811 Facility ID: CA240000081 If continuation sheet 22 of 40 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 11/01/2018 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 topical (applying the medication directly to a part of the body) every six hours as needed for pain, was ordered on October 7, 2018. Resident 2's narcotic count sheet and electronic Medication Administration Record (eMAR) indicated Percocet was signed out and was administered to Resident 2 on the following dates: - October 2, 2018, at 11:41 p.m.; - October 4, 2018, at 1:42 a.m.; - October 6, 2018, at 7:31 a.m. and 3:43 p.m.; - October 7, 2018, at 7:05 a.m. and 6:52 p.m.; - October 8, 2018, at 9:18 a.m.; - October 22, 2018, at 5:37 a.m. and 2:24 p.m.; - October 24, 2018, at 9:32 a.m. and 3:30 p.m.; - October 25, 2018, at 7:25 a.m. and 1:14 p.m.; - October 26, 2018, at 10:23 a.m.; - October 27, 2018, at 3:01 a.m., 1:37 p.m., and 5:57 p.m.; - October 28, 2018 at 3:16 p.m.; - October 29, 2018, at 7:07 a.m. and 12:04 p.m.; and - October 30, 2018 at 7:49 a.m. and 11:51 a.m. There was no documented evidence Resident 2's pain assessment were conducted nor FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OC6811 Facility ID: CA240000081 If continuation sheet 23 of 40 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 11/01/2018 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 completed prior to administration of PRN (as needed) percocet on those dates. Resident 2's care plan, dated October 9, 2018, indicated, "...PROBLEM/NEEDS As manifested by Pain...Arthritis...Rheumatoid Arthritis...back pain...muscle relaxant... APPROACHES/PLAN...Medication as ordered...Use pain management flow sheet...Monitor response to medication..." On November 1, 2018, at 11 a.m., a concurrent record review and interview was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated before administering pain medication to the resident, a pain assessment should be conducted. LVN 1 stated she gave the pain medication to the residents when, the residents verbalized they were in pain or she based it on facial expressions for non-verbal residents. LVN 1 stated a non-pharmacological intervention should be offered and tried before giving a pain medication to the resident. LVN 1 stated Resident 2 had the Percocet for severe pain, Tylenol for mild pain and Robaxin for muscle spasm. LVN 1 stated Resident 2 did not have medication order for moderate pain. LVN 1 stated Resident 2 was able to verbalized she had pain and would request for pain pill. LVN 1 stated Resident 2 was not able to verbalize if her pain was from muscle spasm or her arthritis. In addition, LVN 1 stated she was not able to distinguished when Resident 2's pain was from her arthritis or from muscle spasm. LVN 1 further stated she asked the resident what she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OC6811 Facility ID: CA240000081 If continuation sheet 24 of 40 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 11/01/2018 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 wanted for her pain. LVN 1 stated she did not use the Lidocaine patch or the Voltaren gel because Resident 2 wanted only the pain pill. LVN 1 verified her initials and stated she was the one who signed out for the Percocet and administered to Resident 2 on: - October 7, 2018, at 7:05 a.m.; - October 8, 2018, at 9:18 a.m.; - October 24, 2018, at 9:32 a.m.; - October 25, 2018 at 7:25 a.m. and 1:14 p.m.; - October 29, 2018, at 7:07 a.m. and 12:04 p.m.; and - October 30, 2018, at 7:49 a.m. and 11:51 a.m. LVN 1 stated Resident 2's pain assessment was not conducted nor a non-pharmacological intervention was offered on those dates. LVN 1 stated a pain assessment should be conducted and a non-pharmacological intervention should be offered to the resident before administering the pain medication. On November 1, 2018, at 11:30 a.m., a concurrent record review and interview was conducted with the Registered Nurse (RN). The RN stated before administering pain medication to the resident, a pain assessment should be conducted. The RN stated he gave the pain medication to the residents when, the residents verbalized they were in pain or he based it on facial FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OC6811 Facility ID: CA240000081 If continuation sheet 25 of 40 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 11/01/2018 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 expressions for non-verbal residents. The RN stated a non-pharmacological intervention should be offered and tried before giving a pain medication to the resident. The RN stated Resident 2 had several pain medication ordered. The RN stated he was not clear on the orders on when to use the Robaxin, Lidocaine patch and Voltaren so he did not use it when resident verbalized she was in pain. The RN stated he chose between Percocet and Tylenol when Resident 2 complained of pain and request for the pain medication. The RN verified his initials and stated he was the one who signed out for the Percocet and administered to Resident 2 on: - October 6, 2018, at 3:43 p.m.; and - October 24, 2018, at 3:30 p.m. The RN stated Resident 2's pain assessment was not conducted nor a non-pharmacological intervention was offered on those dates. The RN stated he was not aware a pain flowsheet tool was available to use for the resident's pain assessment. The RN stated he was not oriented by the facility to document the pain assessment nor a non-pharmacological intervention should be offered to the resident before giving the pain medication. The RN stated he was told to answer the pre pain level prompted question on the eMAR before administering the pain medication and to answer the prompt question of "effective" or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OC6811 Facility ID: CA240000081 If continuation sheet 26 of 40 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 11/01/2018 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 "not effective" on the eMAR post pain medication administration. The RN stated a pain assessment should be conducted and a non-pharmacological intervention should be offered to the resident before administering the pain medication. The facility's policy and procedure titled, "Administering Pain Medications," dated October 17, 2018, indicated, "...The purpose of this procedure is to provide guidelines for assessing the resident's level of pain prior to administering analgesic pain medication...Acute pain should be assessed every 30 to 60 minutes after the onset and reassessed as indicated after analgesic relief is obtained...Equipment and Supplies...Standardized pain assessment tools as indicated per facility tool...Pain assessment form and Pain Flow Sheet...Document the following in the resident's medical record: results of the pain assessment..." 3. On November 1, 2018, at 2:48 p.m., a record review was conducted with the Director of Nursing (DON). Resident 30 was readmitted to the facility on July 13, 2018, with diagnoses that included deep vein thrombosis (DVT - a blood clot in a deep vein) on the right leg. Resident 30's physician's order indicated, Xarelto 20 mg to give one tablet by mouth once a day was ordered on July 18, 2018. There was no documented evidence Resident 30 was monitored for signs and symptoms of adverse effect on the use of Xarelto. There was no documented evidence a care plan was developed for Resident 30's use of Xarelto. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OC6811 Facility ID: CA240000081 If continuation sheet 27 of 40 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 11/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC 8951 Granite Hill Dr Riverside, CA 92509 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE In a concurrent interview, the DON stated Resident 30 should have been monitored for any signs and symptoms of adverse effect on the use of Xarelto. The DON stated a care plan should have been developed for Resident 30's used of Xarelto. The facility's policy and procedure titled, "Anticoagulation - Clinical Protocol," dated October 17, 2018, indicated, "...Assess for any signs or symptoms related to adverse drug reactions due to the medication...The staff should use a warfarin (a type of anticoagulant medicines that help prevent blood clots) flow sheet or comparable monitoring tool to follow trends in anticoagulant dosage and response...The staff and physician will monitor for possible complications in individuals who are being anticoagulated, and will manage related problems..." Based on observation, interview, and record review, for three of eight residents (Residents 40, 2, and 30), reviewed for unncecessary medication use, the facility failed to ensure: 1. For Resident 40, a complete pain assessment was conducted and nonpharmacological interventions were offered prior to the administration of tramadol (narcotic pain medication) on multiple occassions for the month of October 2018; 2. For Resident 2, a complete pain assessment was conducted and non-pharmacological interventions were offered prior to the administration of Percocet on multiple occasions for the month of October 2018; and 3. For Resident 30, a monitoring for the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OC6811 Facility ID: CA240000081 If continuation sheet 28 of 40 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 11/01/2018 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 adverse side effects of Xarelto (blood thinner medication used to thin blood) was conducted since the medication was ordered in July 2018. These failures had the potential for the residents to receive unnecessary medications. Findings: 1. On October 31, 2018, Resident 40's record was reviewed. Resident 40 was re-admitted to the facility on June 6, 2018, with diagnoses that included chronic pain syndrome. The physician's order dated June 6, 2018, indicated the following: - tramadol hcl (hydrochloride) 50 mg (milligrams) tablet by mouth every fours hours as needed for moderate pain (pain level 1-3 {mild pain}, 4-6 {moderate pain}, 7-9 {severe pain}, and 10 {excruciating pain}; and - Tylenol 325 mg tablet give two tablets by mouth every four hours PRN (as needed) for mild pain. The electronic Medication Administration Record (eMAR) for October 2018, indicated the licensed nurses administered the PRN tramadol to Resident 40 on the following dates: - October 3, 2018, at 10:05 a.m. (Pain Level {PL} 6) by Licensed Vocational Nurse (LVN) 2; - October 4, 2018, at 8:23 a.m. (PL 6) by LVN 2; - October 5, 2018, at 8:23 a.m. (PL 6) by LVN 2; - October 6, 2018, at 8:01 a.m. (PL 6) by LVN 2; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OC6811 Facility ID: CA240000081 If continuation sheet 29 of 40 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 11/01/2018 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 - October 9, 2018, at 5:15 p.m. (PL 6) by the Registered Nurse (RN); - October 10, 2018, at 7:51 a.m. (PL 6) by LVN 2; - October 11, 2018, at 7:12 a.m., (PL 6) by LVN 2; - October 12, 2018, at 3:35 p.m. (PL 6) by LVN 2; - October 15, 2018, at 7:06 a.m. (PL 6) by LVN 2; - October 17, 2018, at 8:01 a.m. (PL 6) by LVN 2; - October 18, 2018, at 9:54 a.m. (PL 6) by LVN 2; - October 20, 2018, at 6:30 p.m. (PL 5) by the RN ; - October 21, 2018 at 7:47 a.m. (PL 6) by LVN 2; - October 21, 2018, at 3:50 pm (PL 4) by the RN; - October 22, 2018, at 9:53 a.m. (PL 6) by LVN 2; - October 23, 2018, at 7:18 a.m. (PL 6) by LVN 2; - October 24, 2018, at 7:10 a.m. (PL 6) by LVN 2; - October 28, 2018, at 8:06 a.m. (PL 6) by LVN 2; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OC6811 Facility ID: CA240000081 If continuation sheet 30 of 40 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 11/01/2018 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 - October 30, 2018, at 6:44 a.m. (PL 6) by LVN 2; and - October 31, 2018, at 6:59 a.m. (PL 6) by LVN 2. There was no documented evidence of a complete pain assessment conducted, and non-pharmacological interventions offered prior to the administration of tramadol to Resident 40 on those dates. On November 1, 2018, at 8:49 a.m., Resident 40 was observed sitting on his wheelchair in the dining room. Resident 40 was alert but did not verbally respond when asked how he was doing. On November 1, 2018, at 9:21 a.m., Certified Nursing Assistant (CNA) 1 was interviewed. CNA 1 stated she was the nurse assigned to render care on Resident 40 on that shift. CNA 1 stated Resident 40 was non-verbal but was able to communicate through gestures or motions. On November 1, 2018, at 10:19 a.m., Resident 40's record was reviewed with LVN 2. LVN 2 verified her signatures on the dates the tramadol was administered to Resident 40 in the October 2018 eMAR. LVN 2 stated she administered tramadol to Resident 40 on those dates because he had complained of headache. LVN 2 was asked on how she had assessed Resident 40's complain of pain. LVN 2 stated Resident 40 was nonverbal and when Resident 40 had facial grimacing and he placed his hand on his head that would mean he had a headache. LVN 2 further stated she would assess Resident 40's pain scale from 1 - 6 (mild to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OC6811 Facility ID: CA240000081 If continuation sheet 31 of 40 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 11/01/2018 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 moderate pain scale) by asking the resident to nod or shake his head as she counted the number to the resident starting from 1 to 6. LVN 2 was asked how would she assess for severe pain on Resident 40. LVN 2 stated if Resident 40 would start yelling and/or screaming then he had severe pain. LVN 2 further stated Resident 40 did not seem to be in severe pain when she administered tramadol on those dates. LVN 2 stated before administering a PRN pain medication to a resident, she should assess the location, severity, duration of pain on the resident. LVN 1 stated she should also offer non-pharmacological interventions first prior to administering the pain medication to the resident. LVN 2 stated she did not use a pain flow sheet guide when she assessed Resident 40 for pain. LVN 2 stated the computer system for the eMAR only prompted her to measure pain scale on the resident and evaluate the effectiveness after. LVN 2 further stated the computer system for the eMAR did not prompt them to offer non-pharmacological interventions to the resident prior to administering the PRN pain medication. LVN 2 stated she was not aware she had to utilize a pain flow sheet guide when assessing a resident for pain. LVN 2 stated she did not conduct a complete pain assessment on Resident 40 and she did not offer nonpharmacological interventions prior to administering tramadol to Resident 40. On November 2, 2018, at 10:45 a.m., Resident 40's record was reviewed with the RN. The RN verified his signatures on the dates the tramadol was administered to Resident 40 in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OC6811 Facility ID: CA240000081 If continuation sheet 32 of 40 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 11/01/2018 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 October 2018 eMAR. The RN stated he administered tramadol to Resident 40 because he had a headache. RN 1 stated Resident 40 was non-verbal and he used the following for pain assessment - For a pain scale of 4 - Resident 40 has facial grimacing; - For a pain scale of 5 - Resident 40 has tensed expressions - For a pain scale of 6 - Resident has facial grimacing and tensed expression. The RN was unable to answer when asked how would he assess Resident 40 for mild pain and severe pain. The RN stated he only used his personal knowledge when conducting a pain assessment on a resident prior to administering a PRN pain medication. The RN stated he was not aware of the the facility's procedure on conducting a pain assessment on a resident. The RN stated he was not aware he had to utilize a pain assessment tool guide when assessing pain on a resident prior to the administration of a pain medication. The RN stated he should assess for the location, duration, and frequency of pain on the resident, and offer non-pharmacdological interventions first prior to administering a pain medication. The RN stated he did not conducte a complete pain assessment on Resident 40 and offer nonpharmacologic interventions first prior to administering the PRN tramadol on those dates. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OC6811 Facility ID: CA240000081 If continuation sheet 33 of 40 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 11/01/2018 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

F761 Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 12/01/2018 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed, for one of four residents (Resident 37), observed for medication pass administration, to ensure the medication label direction for use on Lasix (diuretic) and metoprolol (medication used to treat high blood pressure), were consistent with the physician's orders. This failure had the potential for a medication FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OC6811 Facility ID: CA240000081 If continuation sheet 34 of 40 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 11/01/2018 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 error. Findings On October 31, 2018, a medication pass observation was conducted with Licensed Vocational Nurse (LVN) 2. LVN 2 prepared Resident 37's medications for administration and it included the following medications with their corresponding direction for use in the medication label: - "METOPROLOL TART (tartrate) 25 mg (milligrams)...Take 0.5 mg tablets by mouth (12.5mg) twice daily for htn (hypertension high blood pressure)...hold if sbp (systolic blood pressure - higher number in a blood pressure reading) < (below) 110, hr (heart rate) < 60..."; and - "FUROSEMIDE (generic name for Lasix) 40 MG...Take 1 tablet by mouth daily for htn..." LVN 2 was not observed to have taken the heart rate measurement for Resident 37 prior to the administration of metoprolol. In a concurrent interview, LVN 2 stated the physician's order in the electronic Medication Administration Record (eMAR) for metoprolol did not include a direction to measure the heart rate prior to administration of the medication. On October 31, 2018, Resident 37's record was reviewed with the Director of Nursing (DON). Resident 37 was re-admitted to the facility on August 6, 2018, with diagnoses that included hypertension. The following physician's orders indicated: "...METOPROLOL TARTRATE 25MG TAB GIVE 12.5 MG...BY MOUTH BID (twice a day) FOR HTN...HOLD IF SBP <100 OR DBP FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OC6811 Facility ID: CA240000081 If continuation sheet 35 of 40 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 11/01/2018 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 (diastolic blood pressure - lower number in a blood pressure reading) < 60...TAKE WITH FOOD," order dated August 6, 2018; and " LASIX 40 MG TABLET PO (by mouth) Q DAILY (everyday)... FOR HTN..." The DON compared the physician's orders for Lasix and metoprolol with the directions for use label printed on the actual medications. The DON stated the physician's orders were not consistent with the direction for use for the medications Lasix and metoprolol. The DON stated the licensed nurses should have identified the discrepancies between the physician's orders and the direction for use in the medication labels and they should have notified and updated the pharmacy. The DON stated the physician's orders for use for Lasix and metoprolol should be consistent with the direction for use in the medication label to avoid medication errors. The facility's policy and procedure titled, "Labeling Medication Containers," dated October 17, 2018 was reviewed. The policy indicated, "...All medication maintained in the facility shall be properly labeled in accordance with current stated and federal regulations... Any medication packaging or conatiners that are inadequately or improperly labeled shall be returned to the issuing pharmacy... The nursing staff must inform the pharmacy of any changes in physician's orders for a medication..."

F791 Routine/Emergency Dental Srvcs in NFs FORM CMS-2567(02-99) Previous Versions Obsolete

F791 Event ID: OC6811 12/01/2018 Facility ID: CA240000081 If continuation sheet 36 of 40 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 11/01/2018 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): 483.55(b)(1)-(5) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.55 Dental Services The facility must assist residents in obtaining routine and 24-hour emergency dental care. §483.55(b) Nursing Facilities. The facility§483.55(b)(1) Must provide or obtain from an outside resource, in accordance with §483.70(g) of this part, the following dental services to meet the needs of each resident: (i) Routine dental services (to the extent covered under the State plan); and (ii) Emergency dental services; §483.55(b)(2) Must, if necessary or if requested, assist the resident(i) In making appointments; and (ii) By arranging for transportation to and from the dental services locations; §483.55(b)(3) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay; §483.55(b)(4) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility; and §483.55(b)(5) Must assist residents who are eligible and wish to participate to apply for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OC6811 Facility ID: CA240000081 If continuation sheet 37 of 40 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 11/01/2018 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 reimbursement of dental services as an incurred medical expense under the State plan. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to assist two of three residents reviewed for dental services (Residents 30 and 34), when the residents request for dentures were not addressed in a timely manner. This failure put the resident at risk for complications for not being able to chew food properly. Findings: 1. On October 29, 2018, at 9:35 a.m., Resident 30 was observed in her wheelchair. Resident 30 had aphasia (a language disorder that affects a person's ability to communicate). Resident 30 pointed out the missing teeth on her lower gum. When asked if she had dentures, Resident 30 shook her head. When asked if she needed dentures, Resident 30 nodded. When asked if she informed the facility, Resident 30 nodded and shrugged her shoulders, appeared to be frustrated and put her hands up. Resident 30 nodded when asked if the facility did not do anything about her request for dentures. On November 1, 2018, at 2:25 p.m., Resident 30's record review was conducted with the Social Services Director (SSD). Resident 30 was admitted to the facility on October 8, 1991. Resident 30 did not have the capacity to understand and make decisions. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OC6811 Facility ID: CA240000081 If continuation sheet 38 of 40 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 11/01/2018 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 30's nutritional assessment, dated July 20, 2018, indicated the resident was on regular, no added salt diet and Resident 30 had missing or poor dentition (condition of the teeth). Resident 30's Social Services Assessment, dated July 17, 2018, indicated Resident 30 had missing teeth. Resident 30's dental care, dated October 3, 2016, indicated the resident consented for tooth extractions and lower dentures. Resident 30's dental care dated on May 2, 2017 and August 8, 2017, had no indication Resident 30's request for lower dentures were addressed. The SSD stated Resident 30 was last seen by the dentist on August 8, 2017. The SSD stated there was no documented evidence Resident 30's request for lower dentures were followed up since October 3, 2016. The SSD further stated "it was not acceptable". 2 .On October 29, 2018, a concurrent observation and interview was conducted with resident 34. Resident 34 was resting on his bed observed to have no teeth. Resident 34 stated he did not have any teeth and has been waiting for his dentures for a long time. On October 31, 2018, at 2:53 p.m., Resident 34's record was reviewed, Resident 34 was admitted to the facility on February 28, 2018. On October 31, 2018, at 8:55 a.m., the Social Services Director (SSD) provided a dental consult for resident 34 dated March 18, 2018. The dental consult report indicated Resident 34 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OC6811 Facility ID: CA240000081 If continuation sheet 39 of 40 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 11/01/2018 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 needed upper and lower dentures. On November 1, 2018, at 2:32 p.m., the SSD was interviewed,. She stated she was not aware there was an issue trying to obtain dentures for Resident 34 until it was brought to her attention. . The facility's Policy and Procedure titled, "Dental Services," revised December 2013, indicated: "...10. Nursing Services is responsible for notifying Social Services of a resident's need for dental services. 11. Social Services personnel will be responsible for assisting the resident/ family in making dental appointments and transportation arrangements as necessary." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OC6811 Facility ID: CA240000081 If continuation sheet 40 of 40