Other·August 16, 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 re-certification survey conducted from May 14, 2018, through May 18, 2018. Representing the California Department of Public Health: Surveyor 22921, HFEN Surveyor 23046, HFEN Surveyor 32192, HFEN Surveyor 36779, HFEN Surveyor 37626, HFEN Surveyor 38477, HFEN Surveyor 38478, HFEN The facility census was 134 residents. The sample size was 37 residents.

F655 SS=D Baseline Care Plan CFR(s): 483.21(a)(1)-(3)

F655 06/11/2018 §483.21 Comprehensive Person-Centered Care Planning §483.21(a) Baseline Care Plans §483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must(i) Be developed within 48 hours of a resident's admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to(A) Initial goals based on admission orders. 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: 5GC811 Facility ID: CA240000087 If continuation sheet 1 of 24 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: _______________ 055581 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JURUPA HILLS POST ACUTE 6401 33rd St 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 (B) Physician orders. (C) Dietary orders. (D) Therapy services. (E) Social services. (F) PASARR recommendation, if applicable. §483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan(i) Is developed within 48 hours of the resident's admission. (ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section). §483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident's medications and dietary instructions. (iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (iv) Any updated information based on the details of the comprehensive care plan, as necessary. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure the baseline care plan was completed within 48 hours of admission for one of 27 sampled residents (Resident 335). This failure had the potential for the resident and the resident's family to be unaware of the treatment and services Resident 335 was receiving prior to the completion of the comprehensive care plan. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5GC811 Facility ID: CA240000087 If continuation sheet 2 of 24 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: _______________ 055581 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JURUPA HILLS POST ACUTE 6401 33rd St 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 Findings: On May 17, 2018, Resident 335's record was reviewed. The record indicated Resident 335 was readmitted to the facility on May 11, 2018, after an acute hospitalization from April 30, 2018, to May 11, 2018. Resident 335's diagnoses included encounter for palliative care (hospice care), dementia (memory loss), hypertension (high blood pressure), osteoporosis (bone-weakening condition) , anxiety (mood disorder), anemia (decrease in the amount of cells in the blood which carried oxygen), atherosclerotic heart disease (heart condition), psychosis (mental disorder), gastroesophageal reflux disease (heart burn), and major depressive disorder (mood disorder). There was no documented evidence in Resident 335's record a baseline care plan, or a comprehensive care plan was completed. On May 17, 2018, at 4:11 p.m., the Minimum Data Set (MDS-an assessment tool) Nurse (MDSN) 1 was interviewed. MDSN 1 was asked when the facility completed the baseline care plan. MDSN 1 stated she was not sure when a baseline care plan summary was completed when a resident was readmitted to the facility. On May 18, 2018, at 8:15 a.m., the Director of Nursing (DON) and Clinical Consultant (CC) were interviewed. The DON stated the facility did not initiate a new base line care plan if the resident returned to the facility within seven days of an acute hospital stay. The CC stated the base line care plan of Resident 335 should have been completed within 48 hours of re-admission since Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5GC811 Facility ID: CA240000087 If continuation sheet 3 of 24 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: _______________ 055581 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JURUPA HILLS POST ACUTE 6401 33rd St 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 335 was readmitted to the facility more than seven days of an acute hospital stay. The facility policy titled, "Care Plans-Baseline," with a revised date of December 2016, was reviewed. The policy indicated: "... To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission..."

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 06/11/2018 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5GC811 Facility ID: CA240000087 If continuation sheet 4 of 24 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: _______________ 055581 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JURUPA HILLS POST ACUTE 6401 33rd St 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 (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan for urinary tract infection (UTI-urine infection) for one of five sampled residents (Resident 82). Findings: On May 14, 2018, at 11:15 a.m., Resident 82 was interviewed. Resident 82 stated she had a UTI and she was on antibiotics about four or five weeks ago, but was still feeling a sensation of burning when she urinated. On May 18, 2018, Resident 82's record was reviewed. Resident 82 was admitted to the facility on March 14, 2018, with diagnoses which included diabetes mellitus (high blood sugar), anxiety disorder (mood disorder), and UTI. The physician order dated April 8, 2018, indicated Resident 82 had an order for "Levaquin (antibiotic) 500 mg (milligrams)... Give one tablet by mouth one time a day for UTI for 7 (seven) days." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5GC811 Facility ID: CA240000087 If continuation sheet 5 of 24 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: _______________ 055581 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JURUPA HILLS POST ACUTE 6401 33rd St 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 There was no documented evidence a comprehensive care plan for UTI was completed for Resident 82. On May 18, 2018, at 2:45 p.m., the Minimum Data Set (MDS-an assessment tool) Nurse (MDSN) 2 was interviewed. MDSN 2 stated he was not able to find a comprehensive care plan for UTI for Resident 82. On May 18, 2018, at 3:55 p.m., the Director of Nursing (DON) was interviewed. The DON confirmed there was no care plan for UTI for Resident 82. The DON stated the care plan for UTI should have been developed for Resident 82. The facility's policy and procedure titled, "Care Plans, Comprehensive Person-Centered," revised December 2016, was reviewed. The policy indicated: "...The Interdisciplinary Team (IDT), in conjunction with the resident and his/ her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident...The comprehensive, person-centered care plan will...Incorporate identified problem areas...Incorporate risk factors associated with identified problems..."

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

F684 06/11/2018 § 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5GC811 Facility ID: CA240000087 If continuation sheet 6 of 24 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: _______________ 055581 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JURUPA HILLS POST ACUTE 6401 33rd St 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 of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 129) received treatment and care in accordance with professional standards of practice when the facility failed to notify the physician of the resident's abnormal laboratory test results. This failure resulted in the physician to not be aware of the resident's condition and the potential for a delay in treatment which may have prevented Resident 129 from being rehospitalized at the acute hospital. Findings: A record review for Resident 129 was conducted on May 16, 2018. Resident 129 was re-admitted to the facility on February 19, 2018, with diagnoses including diabetes mellitus (a disease that results in elevated blood sugar) and chronic obstructive pulmonary disease (COPD, a lung disease that interferes with normal breathing). The laboratory report, dated February 8, 2018, indicated the following laboratory test results for Resident 129 were elevated: a. Glucose (blood sugar) 142, reference range (RR 70-99); b. BUN (blood urea nitrogen, test for kidney and liver function) 32, (RR 7-25); c. Creatnine (test for kidney function) 1.51, (RR 0.70-1.30); FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5GC811 Facility ID: CA240000087 If continuation sheet 7 of 24 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: _______________ 055581 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JURUPA HILLS POST ACUTE 6401 33rd St 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 d. Sodium (an electrolyte) 147, (RR 136-145); e. Chloride (an electrolyte) 112, (RR 98-107); f. BUN/Creatnine ratio (test for kidney function) 21.2 (RR 10.0-20.0); and g. WBC (white blood cells) 13.54, (RR 4.0010.00). There was no documentation indicating the physician had been notified of the abnormal laboratory test results. A nurse's note dated February 11, 2018, at 12:58 a.m., indicated Resident 129 had been sent to the acute hospital for shortness of breath. A nurse's note dated February 11, 2018, at 7:40 a.m., indicated, "Called (initials of acute hospital) and spoke with (name of nurse) who stated that resident would be admitted to (initials of acute hospital) for sepsis (bloodstream infection), PNA (pneumonia-a lung infection) and hypernatremia (elevated sodium in the blood)." An interview was conducted with the Director of Nursing (DON) on May 17, 2018, at 2:37 p.m. The DON reviewed Resident 129's record and verified there was no indication the physician had been notified of the abnormal laboratory results. The DON stated the physician should have been notified of the elevated laboratory test results. The facility policy and procedure titled, "Test Results," revised April 2007, was reviewed. The policy indicated, "...The resident's Attending Physician will be notified of the results of diagnostic tests...The Charge FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5GC811 Facility ID: CA240000087 If continuation sheet 8 of 24 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: _______________ 055581 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JURUPA HILLS POST ACUTE 6401 33rd St 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 Nurse/Nursing supervisor receiving the test results, shall be responsible for notifying the Physician of such test results..."

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 06/11/2018 §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. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure one of 13 sampled residents (Resident 330) did not smoke unsupervised in a non-designated smoking area with an oxygen tank beside him. This failure resulted in the potential for Resident 330 to be burned and created an environment in which a fire could potentially ignite and may lead to severe injury and/or death. Findings: On May 15, 2018, at approximately 8:15 a.m., Resident 330 was observed sitting by himself on a bench in front of the facility near the street. Resident 330 was observed smoking a cigarette. There was a portable oxygen tank observed beside the resident. The nasal cannula (tubing used to deliver oxygen through the nose) was observed draped over the top of the oxygen tank. Resident 330 was observed to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5GC811 Facility ID: CA240000087 If continuation sheet 9 of 24 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: _______________ 055581 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JURUPA HILLS POST ACUTE 6401 33rd St 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 put his cigarette on the ground and then place the cannula in his nose. During a concurrent interview, Resident 330 stated he carried his own cigarettes and lighter. Resident 330 stated he felt uncomfortable with the interview and walked away pulling the oxygen tank behind him. Resident 330 walked into the facility through the front entrance. A record review was conducted for Resident 330 on May 15, 2018, at 8:35 a.m. Resident 330 was re-admitted to the facility on May 12, 2018, with diagnoses that included pneumonia (a lung infection) and chronic obstructive pulmonary disease (COPD, a lung disease that interferes with normal breathing). The "History and Physical," dated May 14, 2018, indicated Patient A had the capacity to undestand and make decisions. A physician's order, dated May 12, 2018, indicated, "O2 (oxygen) AT 2L (liters)/MIN (minute) ROUTINE FOR DX (diagnosis): COPD every shift maintain O2 > (greater than) 90% (percent)." A document titled, "...SMOKING OBSERVATION/ASSESSMENT," dated May 12, 2018, indicated Resident 330 smoked two to five times per day and could light his own cigarette. The section of the document indicating if Resident 330 was safe to smoke with or without supervision was blank. The "Baseline Care Plan," dated May 12, 2018, indicated Resident 330 went out doors to smoke. There was no indication if Resident 330 required supervision while smoking, or if he could smoke unsupervised. A nurse's note dated May 13, 2018, at 5 a.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5GC811 Facility ID: CA240000087 If continuation sheet 10 of 24 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: _______________ 055581 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JURUPA HILLS POST ACUTE 6401 33rd St Riverside, CA 92509 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicated, "Late Entry...spoke with resident while reviewing care plans from previous admission in February 2018. resident [sic] had previous careplan [sic] for smoking in non smoking area with O2. resident [sic] verbalized that he is aware not to do it anymore." A care plan with an initiation and resolved date of May 13, 2018, indicated, "... Focus...RESOLVED: Resident apparently smokes on [sic] non designated area with oxygen...Goal...Will smoke in designated area without bringing oxygen...Interventions/Tasks...RESOLVED:...S taff to monitor for smoking with oxygen..." On May 15, 2018, at 9:09 a.m., Certified Nursing Assistant (CNA) 1 was interviewed. CNA 1 stated residents who used oxygen could smoke but were not allowed to take their oxygen tank when they went out to smoke. On May 15, 2018, at 9:12 a.m., Certified Nursing Assistant (CNA) 2 was interviewed. CNA 2 stated when residents who used oxygen went to smoke they were not allowed to take the oxygen tank outside. On May 15, 2018, at 9:15 a.m., Licensed Vocational Nurse (LVN) 3 was interviewed. LVN 3 stated residents who used oxygen were allowed to smoke but were not permitted to bring the oxygen tank when they smoked. On May 15, 2018, at 10 a.m., the Housekeeper (HK) was interviewed. The HK stated she was supervising the smoking area on the afternoon of May 14, 2018. The HK stated Resident 330 came to the back patio (the designated smoking area) with his oxygen tank. The HK stated she told Resident 330 he could not smoke with the oxygen. The HK stated she reported it to the charge nurse, who went out to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5GC811 Facility ID: CA240000087 If continuation sheet 11 of 24 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: _______________ 055581 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JURUPA HILLS POST ACUTE 6401 33rd St 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 smoking area and told Resident 330 he could not smoke with the oxygen. The HK stated she did not know the name of the nurse who talked to Resident 330. Due to the facility's failure to ensure one resident did not smoke unsupervised in a nondesignated smoking area with an oxygen tank, the Administrator, Director of Nursing, Assistant Administrator, and Clinical Consultant were verbally notified of an Immediate Jeopardy situation on May 15, 2018, at 10:48 a.m. On May 15, 2018, a document titled, "...SMOKING OBSERVATION/ASSESSMENT...Type: Significant Change...," dated May 15, 2018, effective 11:36 (sic) was reviewed. The document indicated Resident 330 smoked two to five times per day, could light his own cigarette, required supervision, and his cigarettes and lighter would be kept by the charge nurse. On May 18, 2018, at 3:08 p.m., the Director of Nursing (DON) was interviewed. The DON stated they were not able to complete the initial smoking assessment for Resident 330, dated May 12, 2018, and verified the assessment was not completed. The DON was asked about the late entry on May 13, 2018, at 5 a.m., indicating Resident 330 had a previous care plan for smoking in non-smoking areas with his oxygen. The DON stated she worked the night shift on May 12, 2018, and noted that Resident 330 had been in the facility before. The DON stated she told Resident 330 not to smoke with his oxygen, and also informed the on-coming nurse to keep an eye on him because he had a history of smoking with his oxygen. The DON stated, "I should have been more aggressive, more firm FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5GC811 Facility ID: CA240000087 If continuation sheet 12 of 24 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: _______________ 055581 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JURUPA HILLS POST ACUTE 6401 33rd St Riverside, CA 92509 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE with him regarding not bringing his oxygen outside to smoke." According to the Centers for Disease Control and Prevention (CDC) MMWR Weekly, dated August 8, 2008, "...Medical oxygen can saturate clothing, fabric, and hair... A fire, such as a lit cigarette, will burn faster and hotter in an oxygen-enriched environment..." According to the U.S. Fire Administration, "...Medical oxygen can explode if a flame or spark is near. Even if the oxygen is turned off, it can still catch on fire..." The facility policy and procedure titled, "Smoking Policy - Residents," revised July 2017, was reviewed. The policy indicated, "...Smoking is only permitted in designated resident smoking areas...Oxygen use is prohibited in smoking areas...The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include...Ability to smoke safely with or without supervision..."

F692 SS=D Nutrition/Hydration Status Maintenance CFR(s): 483.25(g)(1)-(3)

F692 06/11/2018 §483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5GC811 Facility ID: CA240000087 If continuation sheet 13 of 24 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: _______________ 055581 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JURUPA HILLS POST ACUTE 6401 33rd St 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 preferences indicate otherwise; §483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health; §483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure a dietician conducted a consultation when ordered by the physician for one of four sampled residents (Resident 76). This failure caused Resident 76 not to receive the services of a dietician when her nutritional status declined. Findings: On May 16, 2018, Resident 76 was observed to have significant edema on both lower extremities. On May 18, 2018, at 10:35 a.m., a concurrent interview and a review of Resident 76's record was conducted with the Director of Nurses (DON) and the Registered Dietician (RD). The DON confirmed the nurse's progress note dated February 7, 2018, indicated Resident 76's pre-albumin (blood test which measures nutritional status, specifically protein; low prealbumin may cause edema) was 13 (normal range is 17-34). The DON confirmed the nurse's note indicated the nurse notified the physician of the low prealbumin level on February 7, 2018, and the physician ordered a consultation by the RD. The DON stated the only RD consultation in the record since February 7, 2018, was on April 25, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5GC811 Facility ID: CA240000087 If continuation sheet 14 of 24 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: _______________ 055581 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JURUPA HILLS POST ACUTE 6401 33rd St 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 2018 (more than two months after physician ordered the RD consultation). The DON confirmed the RD consultation should have been completed in a timely manner when it was ordered. During the concurrent interview with the RD, the RD stated a pre-albumin level indicated a resident's nutritional status. The RD stated a low pre-albumin of 13 indicated a low protein level. On May 18, 2018, the record of Resident 76 record was reviewed. Resident 76 was admitted to the facility on April 24, 2018, with diagnosis which included edema (swelling). The recapitulated (summarized) physician's orders indicated an order, dated March 9, 2018, to "Monitor for edema..." The care plan titled, "The resident is at nutritional risk..." The care plan indicated, "...Refer to RD as needed...01/17/2017..." The facility policy and procedure titled, "Dietitian," revised March 2010, was reviewed. The policy indicated, "Our facility's Dietitian is responsible for...Assessing nutritional needs of residents..."

F697 SS=D Pain Management CFR(s): 483.25(k)

F697 06/11/2018 §483.25(k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5GC811 Facility ID: CA240000087 If continuation sheet 15 of 24 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: _______________ 055581 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JURUPA HILLS POST ACUTE 6401 33rd St 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, the facility failed to ensure the physician was notified the resident's pain medication was ineffective, after the hospice agency was called and did not return the facility's call the on May 16, 2018, for one of three residents (Resident 76). This failure resulted in Resident 76's pain not to be treated timely. Findings: On May 14, 2018, at 10 a.m., Resident 76 was observed sitting up in bed with some facial wincing observed. Resident 76 stated she was "ok" but her "condition" had become worse. On May 16, 2018, at 8:15 a.m., a concurrent observation and interview was conducted with Resident 76. Resident 76 was observed sitting up in bed. Resident 76 stated her pain was "alright." Resident 76 was observed wincing and repositioning during the interview. Resident 76 stated her pain was eight on a scale of one to ten (8/10; ten being the worst pain). On May 16, 2018, at 9:08 a.m, a concurrent observation and interview was conducted with Resident 76. Resident 76 was observed sitting up in bed with facial grimacing and complaining of pain of 9/10. Resident 76 stated she received pain medication at about 5:40 a.m. Resident 76 stated it did not help. Resident 76 stated she had pain "bad" like this for "a long time." Resident 76 stated the pain was in her "tail bone," between her buttocks, and in her legs. Resident 76 was observed to constantly adjust positioning during the interview, which she stated was due to pain and trying to get FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5GC811 Facility ID: CA240000087 If continuation sheet 16 of 24 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: _______________ 055581 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JURUPA HILLS POST ACUTE 6401 33rd St 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 comfortable. On May 16, 2018, at 9:26 a.m., Licensed Vocational Nurse (LVN) 3 was observed to ask Resident 76 how much pain she had and Resident 76 was observed to state, "9." Resident 76 was observed to tell LVN 3 the pain medication did not work and had not been working for a long time. On May 17, 2018, at 9:16 a.m., an interview was conducted with LVN 3. LVN 3 stated she called the hospice two times on May 16, 2018, to notify them Resident 76's pain medication was ineffective. LVN 3 stated the hospice did not call back. LVN 3 stated she did not call Resident 76's physician. On May 17, 2018, at 4 p.m., an interview was conducted with LVN 4. LVN 4 stated she was assigned to Resident 76 on May 16, 2018. LVN 4 stated she did not call the hospice. LVN 4 reviewed Resident 76's record and confirmed the dose of Norco she administered last night, May 16, 2018, at 9:11 p.m. for pain was ineffective. LVN 4 stated the hospice did not return the call and she did not call them. LVN 4 confirmed she should have notified Resident 76's physician about the ineffective pain medication. On May 18, 2018, Resident 76's record was reviewed. The record indicated Resident 76 had a diagnosis of chronic pain syndrome and muscle spasms (contractions of the muscles). The physician's order, dated May 1, 2018, indicated, "...admit to (name of hospice) ...with the diagnosis of end stage heart disease..." The care plan titled, "At risk for pain...," initiated on January 1, 2018, indicated, "...Notify MD if pain meds is (sic) not effective..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5GC811 Facility ID: CA240000087 If continuation sheet 17 of 24 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: _______________ 055581 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JURUPA HILLS POST ACUTE 6401 33rd St 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 "Progress Notes" indicated the following: - On May 15, 2018, at 7 a.m.: "...Norco (pain medication)...ineffective...Follow-up Pain Scale...6...;" - On May 16, 2018, at 9:11 p.m.: "...Norco...ineffective...Follow-up Pain Scale...4...;" - On May 17, 2018, at 2:26 a.m.: "...Norco...ineffective...Follow-up Pain Scale...7...;" and - On May 17, 2018, at 12:11 p.m.; '...Norco...ineffective...Follow-up Pain Scale...4..." On May 18, 2018, at 10:35 a.m., the Director of Nursing (DON) was interviewed. The DON confirmed there was no documented evidence the hospice and/or physician was notified these doses of pain medication were ineffective. The DON stated when a resident receives pain medication and it is ineffective, the nurse is supposed to notify the hospice or the physician. The DON stated the nurse should have notified the physician when the hospice did not call back within a few hours. The facility policy and procedure titled, "Pain Assessment and Management," revised March 2015, was reviewed. The policy indicated, "Monitoring and Modifying Approaches...If pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated...Report the following information to the physician or practitioner...Significant changes in the level of the resident's pain...Prolonged, unrelieved pain FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5GC811 Facility ID: CA240000087 If continuation sheet 18 of 24 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: _______________ 055581 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JURUPA HILLS POST ACUTE 6401 33rd St 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 despite care plan interventions..."

F880 SS=E Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 06/11/2018 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5GC811 Facility ID: CA240000087 If continuation sheet 19 of 24 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: _______________ 055581 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JURUPA HILLS POST ACUTE 6401 33rd St 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 infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: 3. On May 14, 2018, at 11:15 a.m., a nebulizer mask was observed on top of Resident 335's night stand beside a suction machine, not stored in a storage bag and not in use. LVN 6 was interviewed on May 14, 2018, at 11:15a.m. LVN 6 stated the nebulizer mask should be kept inside a plastic bag when not in use. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5GC811 Facility ID: CA240000087 If continuation sheet 20 of 24 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: _______________ 055581 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JURUPA HILLS POST ACUTE 6401 33rd St Riverside, CA 92509 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On May 14, 2018, Resident 335's record was reviewed. The record indicated Resident 335 was readmitted to the facility on May 11, 2018, with diagnoses which included encounter for palliative care (hospice care). The physician's orders for Resident 335 were reviewed on May 17, 2018. The physician's order, dated May 11, 2018, indicated, "... Ipratropium/Albuterol (Proventil- type of breathing treatment medication) 1 unit dose via nebulizer Q (every) 4 H (hours) routine..." On May 17, 2018, at 3:42 p.m., the ICN was interviewed. The ICN stated the licensed nurses should provide the resident with a clean plastic bag and store the nebulizer mask inside the bag after each use. The facility policy titled, "Prevention of Infection Respiratory Equipments," revised November 2011, was reviewed. The policy indicated: "... Infection Control Considerations Related to Medication Nebulizers... Store the circuit in plastic bag, marked with date and resident's name, between uses..." 2. On May 17, 2018, at 10:41 a.m., LVN 1 was observed performing wound care to the three wounds of Resident 76. During the wound care procedure of the first wound, LVN 1 was observed to put on gloves. LVN 1 was observed to grab the sides of the overbed table on areas not covered by the protective barrier with both gloved hands. LVN 1 then proceeded to begin the wound care to the wound on the left upper buttock. During the wound care procedure of the second wound, LVN 1 was observed to put on gloves. LVN 1 was observed to grab the sides FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5GC811 Facility ID: CA240000087 If continuation sheet 21 of 24 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: _______________ 055581 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JURUPA HILLS POST ACUTE 6401 33rd St 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 of the overbed table with both gloved hands. LVN 1 then opened Resident 76's incontinent brief with her glove right hand and pushed it down towards the bed. LVN 1 then picked up the moistened gauze with her right hand and cleaned the left upper buttock wound and performed the wound care. LVN 1 did not change her gloves nor perform hand hygiene in between touching several items and performing the wound care. LVN 1 was interviewed immediately after she completed the wound care. LVN 1 confirmed she grabbed the overbed table with her gloved hands during the wound care procedure. LVN 1 confirmed she opened Resident 76's incontinent brief by pushing it down towards the bed with her gloved hands. LVN 1 stated she should not have touched the overbed table or Resident 76's incontinent brief during the wound care procedure. On May 17, 2018, at 3:17 p.m., an interview was conducted with the Infection Control Nurse (ICN). The ICN stated once the nurse washes her hands and puts on clean gloves to perform wound care, she is not supposed to touch anything with her gloved hands except the patient's wound. The ICN confirmed the nurse was not supposed to touch the overbed table or the patient's brief with the clean gloves on during the wound care procedure. On May 17, 2018, the facility policy and procedure titled, "Handwashing/Hand Hygiene," revised August 2015, was reviewed. The policy stated, "This facility considers hand hygiene the primary means to prevent the spread of infections...Use an alcohol-based hand rub...or soap...and water... Before preparing or handling medications...Before moving from a contaminated body site to a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5GC811 Facility ID: CA240000087 If continuation sheet 22 of 24 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: _______________ 055581 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JURUPA HILLS POST ACUTE 6401 33rd St 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 clean body site during resident care...After contact with a resident's intact skin...After handling used dressings..." Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented for three of 27 sampled residents (Residents 121, 76, and 335) when: 1. For Resident 121, the nurse did not change her gloves or perform hand hygiene after she repositioned the resident's foot before administering eye drops and medication via the resident's gastrostomy tube (g-tube, a tube inserted through the abdomen that delivers nutrition and medication); 2. For Resident 76, the nurse touched the overbed table and the resident's brief with clean gloves while performing wound care; and 3. For Resident 335, the nebulizer mask (plastic mask used for breathing treatments) was not kept in a storage bag when not in use. These failures increased the potential for crosscontamination and the potential for the residents to develop an infection. Findings: 1. During the medication administration observation on May 17, 2018, at 12 p.m., Licensed Vocational Nurse (LVN) 5 was observed to put on gloves and repositioned Resident 121's right foot, which was wrapped in gauze, with her gloved hands. Afterwards, LVN 5 was observed to proceed to administer eye drops in Resident 121's eyes. LVN 5 did not change her gloves or perform hand hygiene prior to administering the eye drops. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5GC811 Facility ID: CA240000087 If continuation sheet 23 of 24 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: _______________ 055581 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JURUPA HILLS POST ACUTE 6401 33rd St Riverside, CA 92509 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE LVN 5 was then observed to continue on to check the placement of Resident 121's g-tube and proceeded to administer medication through the g-tube. LVN 5 did not change her gloves or perform hand hygiene prior to checking the placement of the g-tube and administering the medication. An interview was conducted with LVN 5 on May 17, 2018, at 12:27 p.m. LVN 5 stated she should have washed her hands and changed her gloves after adjusting Resident 121's foot. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5GC811 Facility ID: CA240000087 If continuation sheet 24 of 24