Other·June 21, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated standard survey for the investigation of one complaint. Complaint number CA00526606. Representing the California Department of Public Health: Surveyor Federal ID number 33841, HFEN The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Five deficiencies were issued for complaint number CA00526606.

F157 SS=D NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC) CFR(s): 483.10(g)(14)

F157 06/19/2017 (g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident’s physician; and notify, consistent with his or her authority, the resident representative(s) when there is(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident’s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening 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: X0JR11 Facility ID: CA240000091 If continuation sheet 1 of 32 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 06/05/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is(A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative (s). This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to notify the physician when: 1. A medication (Harvoni-prescription medicine to treat hepatitis C) prescribed for chronic hepatitis (liver inflammation) was not administered for six months due to unavailability for Resident A; and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X0JR11 Facility ID: CA240000091 If continuation sheet 2 of 32 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 06/05/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 2. An orthopedic doctor needed to discuss new antibiotic (dicloxacillin) regimen prior to use for Resident A. These failures had resulted in the physician not being aware of the current status of treatment for Resident A which could delay the healing process for Resident A. Findings: 1. On March 20, 2017, at 8:38 a.m., an unannounced visit to the facility was conducted to investigate a complaint related to quality care issues. Resident A's record was reviewed. Resident A was admitted to the facility on August 15, 2016, with diagnoses which included type 2 diabetes mellitus (life-long disease in which there is a high level of sugar in the blood). Resident A's physician order dated October 12, 2016, indicated an order for Harvoni tablet to be given once a day for chronic hepatitis C (viral disease that leads to swelling/ inflammation of the liver). Review of A's Medication Administration Record (MAR) dated October 1 to 31, 2016, was reviewed and indicated: a. October 13, 17, 22, 24, 25, 28, and 31, 2016, - documented as (9); b. October 18, 19, and 20, 2016, - documented as (5); and c. October 14-16, 21, 23, 26, 27, 29, and 30, 2016, - documented with checked mark. The medication administration notes dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X0JR11 Facility ID: CA240000091 If continuation sheet 3 of 32 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 06/05/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 13 to 31, 2016, were reviewed and indicated Resident A's Harvoni medication was being held due to pending authorization from the insurance and was unavailable. The MAR codes indicated: code (9) meant other/see nurse notes, code (5) meant hold/see nurse notes, check mark meant administered. Resident A's MAR dated November 1 to 30, 2016, indicated: a. November 1, 7, 8, 13, 14, 16-19, 21, 27-30, 2016, -were documented with a check mark; and b. November 2-6, 9-12, 15, 20, 22, 24, 26, 2016- were documented (9). The medication administration notes dated November 1 to 30, 2016, were reviewed and indicated the Harvoni medication was pending insurance authorization (1 month after it was initially ordered). Resident A's December 1 to 31, 2016, (2 months after the Harvoni was initially ordered) MAR indicated: a. December 1, 2, 4, 6-9, 14, 17-20, 25, 26, 29, and 31, 2016- was documented with a check mark; b. December 3, 5, 10-13, 15, 16, 21, 22, 24, 27 -28, 2016 - were documented as (9); and c. December 23, 2016, -was documented as (5). The medication administration notes dated December 1 to 31, 2016, were reviewed and indicated Resident A's Harvoni was unavailable, awaiting MD (medical doctor) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X0JR11 Facility ID: CA240000091 If continuation sheet 4 of 32 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 06/05/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 clarification, awaiting liver biopsy (medical removal of tissue from a living subject to determine the presence or extent of a disease). Resident A's MAR dated January 1 to 31, 2017, (3 months after the Harvoni was initially ordered by the physician) indicated: a. January 1, 2, 4, 5, 10-13, 16, and 28, 2017, was documented as (9); b. January 3, 6-9, 14, 15, 20, 21, 26, 27, and 31, 2017, were documented with check mark; and c. January 17-19, 22-24, 29-30, 2017, were documented as (5). The medication administration notes dated January 1 to 31, 2017, was reviewed and indicated the Harvoni medication was held pending liver biopsy and awaiting authorization. Resident A's Medication Administration Record (MAR) dated February 1 to 28, 2017, (4 months after the medication was ordered by the physician), indicated: a. February 1 to 3, 5-8, 11, 13-14, 19-20, 2526, 2017, were documented with check mark; b. February 4, 9, 12, 15-18, 21-24, 27-28, 2017, were documented as (9); and c. February 10, 2017, was documented as (5). The medication administration notes dated February 1 to 28, 2017, were reviewed and indicated Harvoni medication was held due to unavailability and pending authorization. Resident A's MAR dated March 1 to 27, 2017, was reviewed and indicated the following: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X0JR11 Facility ID: CA240000091 If continuation sheet 5 of 32 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 06/05/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 a. March 1-2, 5-8, 11-13, 17, 19, 24, 27, 2017, were coded 9; b. March 3-4, 9-10-14-16, 20-22, 20-23, 25-26, 2017, was coded with a checked mark. Resident A's progress notes as related to administration of Harvoni dated March 1 to 26, 2017, were reviewed and indicated, "awaiting appt (appointment with ID (infectious disease) doc (doctor) for authorization "and "not available from pharmacy". The above documentation from October 2016 to March 2017, indicated Resident A's Harvoni was being held due to unavailability and was pending authorization from insurance since October 2016. There was no documented evidence the concern related to Resident A's Harvoni medication was discussed with the physician and/or the ID doctor since the facility was not able to obtain it since October 2016. On March 27, 2017, at 10:25 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed. She stated Resident A's Harvoni was unavailable and was on hold pending pharmacy to deliver. LVN 1 stated she needed to follow-up with the pharmacy. On March 27, 2017, at 11:10 a.m., the Director of Nursing (DON) was interviewed. He stated if a medication could not be obtained from the pharmacy the nurses were supposed to notify the doctor regarding unavailability of the medication. The DON stated the nurses were expected to let him and the administrator knew for them to intervene regarding the unavailable medications. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X0JR11 Facility ID: CA240000091 If continuation sheet 6 of 32 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 06/05/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 March 27, 2017, at 12 p.m., the DON stated the information he gathered was since October 2016, Resident A had not received Harvoni from the facility. There was no documented evidence Resident A's physician or infectious disease doctor was notified regarding the unavailability of Harvoni medication and if an alternative could be provided until March 28, 2017. The progress note dated March 28, 2017, at 12:26 p.m.(5 months after the initial physician order for Harvoni) was reviewed and indicated, "Placed call to (name of ID doctor) office...Requested for (name of ID doctor) to issue order for Harvoni as (name of insurance) will only accept order from Infectious disease Doctor..." At 1:33 p.m., "Received call from (name of doctor) with order to discontinue the Harvoni due to current treatment with antibiotics. Stated she will consider ordering Harvoni when antibiotic is complete..." 2. On March 27, 2017, Resident A's record was reviewed. Resident A was admitted to the facility on August 15, 2016, with diagnoses which included type 2 diabetes mellitus (lifelong disease in which there is a high level of sugar in the blood). Resident A's progress note dated February 17, 2017, indicated," resident (Resident A) came back form (sic) orthopedic md (medical doctor), with an order for dicloxacillin, 500 bid, with no stop date called md office to clarify, spoke with (name of clinic staff), she informed me that (name of doctor) will contact the pcp (primary care physician) first before resident starts abt (antibiotic)." Resident A's progress note dated February 21, 2017, (5 days after the orthopedic FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X0JR11 Facility ID: CA240000091 If continuation sheet 7 of 32 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 06/05/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 appointment), indicated the orthopedic doctor's clinic was called to get clarification on how long the dicloxacillin was supposed to be given. The document indicated not to start the medication until the orthopedic doctor talks to the pcp. Resident A's progress note dated March 1, 2017, (13 days after the orthopedic appointment), the orthopedic doctor was still unable to speak with Resident A's pcp. There was no documented evidence the pcp at the facility was notified and made aware related to the need for orthopedic doctor to talk to the pcp so the antibiotic could be initiated for Resident A since February 17, 2017. On May 2, 2017, at 11:34 a.m., the Assistant Director of Nursing (ADON) was interviewed. She stated the nurses were supposed to notify the primary doctor with any new orders obtained from outside consults.

F281 SS=D SERVICES PROVIDED MEET PROFESSIONAL STANDARDS CFR(s): 483.21(b)(3)(i)

F281 06/20/2017 (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must(i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to ensure the services provided met the professional standards when: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X0JR11 Facility ID: CA240000091 If continuation sheet 8 of 32 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 06/05/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 1. Resident A did not receive a medication for chronic hepatitis (Harvoni- to treat hepatitis C) as prescribed by the physician. This failure had resulted in Resident A not receiving a medication indicated to assist the resident's health to progress in accordance to the physician's plan of treatment. 2. Resident A's medication (Harvoni) was consistently being documented as administered (for 6 months) despite of the medication being unavailable at the facility. This failure had resulted in Resident A's record not to accurately reflect the status of treatment being received at the facility by Resident A. Findings: On March 27, 2017, at 8:38 a.m., an unannounced visit to the facility was conducted to investigate a complaint related to a quality care issue. On March 27, 2017, Resident A's record was reviewed. Resident A was admitted to the facility on August 15, 2016, with diagnoses which included type 2 diabetes mellitus (lifelong disease in which there is a high level of sugar in the blood). Resident A's physician order dated October 12, 2016, indicated an order for Harvoni tablet to be given once a day for chronic hepatitis C (viral disease that leads to swelling/ inflammation of the liver). Review of A's Medication Administration Record (MAR) dated October 1 to 31, 2016, was reviewed and indicated: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X0JR11 Facility ID: CA240000091 If continuation sheet 9 of 32 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 06/05/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 a. October 13, 17, 22, 24, 25, 28, and 31, 2016, - documented as (9); b. October 18, 19, and 20, 2016, - documented as (5); and c. October 14-16, 21, 23, 26, 27, 29, and 30, 2016, - documented with a check mark. According to the MAR codes, the codes 9 meant other/ see nurse notes, 5 meant hold/see nurse notes, and check mark as administered. The medication administration notes dated October 13 to 31, 2016, were reviewed and indicated Resident A's Harvoni medication was being held due to pending authorization from the insurance and was unavailable. Resident A's MAR dated November 1 to 30, 2016, indicated: a. November 1, 7, 8, 13, 14, 16-19, 21, 27-30, 2016, -were documented as given; and b. November 2-6, 9-12, 15, 20, 22, 24, 26, 2016- were documented (9). The medication administration notes dated November 1 to 30, 2016, were reviewed and indicated the Harvoni medication was pending insurance authorization (1 month after it was initially ordered). Resident A's December 1 to 31, 2016, (2 months after the Harvoni was initially ordered) MAR indicated: a. December 1, 2, 4, 6-9, 14, 17-20, 25, 26, 29, and 31, 2016- was documented with a check mark; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X0JR11 Facility ID: CA240000091 If continuation sheet 10 of 32 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 06/05/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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. December 3, 5, 10-13, 15, 16, 21, 22, 24, 27 -28, - were documented as (9); and c. December 23, 2016, -was documented as (5). The medication administration notes dated December 1 to 31, 2016, were reviewed and indicated Resident A's Harvoni was unavailable, awaiting MD (medical doctor) clarification, awaiting liver biopsy (medical removal of tissue from a living subject to determine the presence or extent of a disease). Resident A's MAR dated January 1 to 31, 2017, (3 months after the Harvoni was initially ordered by the physician) indicated: a. January 1, 2, 4, 5, 10-13, 16, and 28, 2017, was documented as (9); b. January 3, 6-9, 14, 15, 20, 21, 26, 27, and 31, 2017, were documented with a check mark; and c. January 17-19, 22-24, 29-30, 2017, were documented as (5). The medication administration notes indicated the Harvoni medication was held pending liver biopsy and awaiting authorization. Resident A's Medication Administration Record (MAR) dated February 1 to 28, 2017, (4 months after the medication was ordered by the physician), indicated: a. February 1 to 3, 5-8, 11, 13-14, 19-20, 2526, 2017, - were documented with a check mark; b. February 4, 9, 12, 15-18, 21-24, 27-28, 2017, - were documented as (9); and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X0JR11 Facility ID: CA240000091 If continuation sheet 11 of 32 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 06/05/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 c. February 10, 2017, - was documented as (5). The medication administration notes dated February 1 to 28, 2017, were reviewed and indicated Harvoni medication was held due to unavailability, and pending authorization. Resident A's MAR dated March 1 to 27, 2017, was reviewed and indicated the following: a. March 1-2, 5-8, 11-13, 17, 19, 24, 27, 2017, were coded 9; b. March 3-4, 9-10-14-16, 20-22, 20-23, 25-26, 2017, was coded with a checked mark. Resident A's progress notes dated March 1 to 26, 2017, were reviewed and indicated, "awaiting appt (appointment with ID (infectious disease) doc (doctor) for authorization "and "not available from pharmacy". The above documentation from October 2016 to March 2017, indicated Resident A's Harvoni was being held due to unavailability and was pending authorization from insurance since October 2016. On March 27, 2017, at 10:25 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed. She stated Resident A's Harvoni was unavailable and was on hold pending pharmacy to deliver. LVN 1 stated she needed to follow-up with the pharmacy. Resident A's MAR dated March 1 to 27, 2017, indicated LVN 1 had documented the medication Harvoni as administered multiple times (March 19, 20, 21, 25, and 26, 2017). On March 27, 2017, at 11:10 a.m., the Director of Nursing (DON) was interviewed. He stated if FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X0JR11 Facility ID: CA240000091 If continuation sheet 12 of 32 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 06/05/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 a medication could not be obtain from the pharmacy the nurses were supposed to notify the doctor regarding unavailability of the medication. The DON stated the nurses were expected to let him and the administrator knew for them to intervene regarding the unavailable medications. On March 27, 2017, at 12 p.m., the DON stated the information he gathered was since October 2016, Resident A had not receive Harvoni from the facility. There was no documented evidence an intervention was initiated to ensure Resident A received Harvoni or an alternative as ordered by the physician. There was no documented evidence Resident A's physician or infectious disease doctor was notified regarding the unavailability of the Harvoni medication and if an alternative could be provided to Resident A. On April 20, 2017, at 10:15 a.m., LVN 2 was interviewed. He stated if a medication was unavailable the nurses were expected to call the pharmacy to follow-up on delivery. LVN 2 stated the nurse was supposed to call the doctor to make them aware of unavailability of the medication. On April 25, 2017, at 10:31 a.m., LVN 3 was interviewed. She stated she had never received Resident A's Harvoni from the facility pharmacy. LVN 3 stated the appropriate way of administering medication should be for the nurse to check orders, check medication in accordance with the physician order, administer the medication and document what was administered. She stated if she knew the medication was unavailable she should have not documented it as given. LVN 3 stated the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X0JR11 Facility ID: CA240000091 If continuation sheet 13 of 32 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 06/05/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 appropriate code should have been (9) and documentation should have been noted in the nurse's note as not given. Resident A's MAR dated October 13 to 31, 2017, indicated LVN 3 had documented the medication Harvoni as administered for three consecutive days (October 14, 15, and 16, 2017). On May 2, 2017, at 7:59 a.m., LVN 4 stated she follows the rule in medication administration of pour, pass then document. She agreed if there was no medication which was passed then there should not be a documentation of medication being administered. On May 2, 2017, at 2:40 p.m., Resident A's MAR was reviewed with LVN 4. She aknowledged the multiple times she had documented Resident A having received the Harvoni medication from October 2016 to January 2017. LVN 4 stated she could have overlooked documenting that it (Harvoni) was given when the medication was unavailable to be administered to Resident A. She stated she should have corrected the administered entries when she knew the Harvoni medication was not provided to Resident A due to unavailability. Resident A's MAR dated October 13 to 31, 2016, indicated LVN 4 had documented the medication Harvoni as administered multiple times (3 of 3 times she had taken care of Resident A) on October 21, 26, and 27, 2016. Resident A's MAR dated November 1 to 30, 2017, indicated LVN 4 had documented the medication Harvoni as administered multiple times (5 of 7 times she had taken care of Resident A) on November 1, 7, 8, 14, and 19, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X0JR11 Facility ID: CA240000091 If continuation sheet 14 of 32 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 06/05/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 2016. Resident A's MAR dated December 1 to 31, 2016, indicated LVN 4 had documented the medication Harvoni as administered multiple times (10 of 11 times she had taken care of Resident A) on December 1, 2, 7, 8, 14, 19, 20, 25, 26, and 31, 2016. Resident A's MAR dated January 1 to 31, 2017, indicated LVN 4 had documented the medication Harvoni as administered multiple times ( 8 of 8 times she had taken of Resident A) on January 3, 8, 9, 14, 20, 21, 26, and 27, 2017. Resident A's MAR dated February 1 to 28, 2017, indicated LVN 4 had documented the medication Harvoni as administered multiple times (10 of 10 times she had taken of Resident A) on February 1, 2, 7, 8, 13, 14, 19, 20, 25, and 26, 2017. Resident A's MAR dated March 1 to 27, 2017, indicated LVN 4 had documented the medication Harvoni as administered multiple times (6 of 6 times she had taken care of Resident A) on March 3, 4, 9, 10, 15, and 16, 2017. On May 2, 2017, at 3:15 p.m., the facility pharmacy consultant stated Harvoni was costly and was only available at special outside pharmacy which did not include the current pharmacy being used by the facility. There was no documented evidence Resident A's Harvoni was ordered from outside pharmacy from October to March 2017. On May 3, 2017, at 9:58 a.m., the DON stated a medication which was unavailable and not administered should be documented as not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X0JR11 Facility ID: CA240000091 If continuation sheet 15 of 32 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 06/05/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 given. The facility policy and procedure was reviewed. The policy titled, " Administering Medications," revised December 2012, indicated, "...Medications shall be administered in a safe and timely manner, and as prescribed...Medications must be administered in accordance with the orders, including any required time frame...if a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose..." A review of the Nursing Practice Act Business & Profession Code indicated,"...Direct and indirect patient care services, including, but not limited to, the administration of medications and therapeutic agents, necessary to implement a treatment, disease prevention, or rehabilitative regimen ordered by and within the scope of licensure of a physician... RN (registered nurse) administers meds and implements treatment regimens based on patient specific physician's orders..." According to "Lippincott Nursing Center 8 rights of medication administration,"...1. right patient...2. Right medication...Check the order 3. Right dose...4. Right route... 5. Right time...6. Right documentation...* Document adminstration AFTER giving the ordered medication. * Chart the time, route, and any other specific information as necessary. For example, the site of an injection or any laboratory value or vital sign that needed to be checked before giving the drug. 7. Right reason...8. Right response... "

F309 SS=D PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING FORM CMS-2567(02-99) Previous Versions Obsolete

F309 Event ID: X0JR11 06/20/2017 Facility ID: CA240000091 If continuation sheet 16 of 32 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 06/05/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 CFR(s): 483.24, 483.25(k)(l) 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident’s comprehensive assessment and plan of care. 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, including but not limited to the following: (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. (l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to ensure the necessary care and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X0JR11 Facility ID: CA240000091 If continuation sheet 17 of 32 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 06/05/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 services was provided for one (Resident A) of three sampled residents when there was no assessment and intervention initiated for Resident A's consistent refusal of medication (dicloxacillin-antibiotic for bone infection). This failure had resulted in Resident A not to receive consistent treatment for the bone infection which could contribute in delayed healing. Findings: On March 27, 2017, at 10:35 a.m., Resident A was interviewed. Resident A stated she had previous concern with an antibiotic given to her during her appointment on February 17, 2017. She stated she refused to take it because she felt it was too strong for her. Resident A stated she had requested to talk to the physician about it but did not get the chance. She stated she felt she was being put under the carpet. On March 27, 2017, Resident A record was reviewed. Resident A was admitted to the facility on August 15, 2016, with diagnoses which included type 2 diabetes mellitus (lifelong disease in which there is a high level of sugar in the blood). Resident A's physician order (from an orthopedic appointment) dated February 17, 2017, indicated an order for dicloxacillin 500 mg 1 tab (tablet) BID (two times a day). Resident A's progress note dated February 17, 2017, indicated," resident (Resident A) came back form (sic) orthopedic md (medical doctor), with an order for dicloxacillin, 500 bid, with no stop date called md office to clarify, spoke with (name of clinic staff), she informed me that (name of doctor) will contact the pcp (primary care physician) first before resident starts abt (antibiotic)." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X0JR11 Facility ID: CA240000091 If continuation sheet 18 of 32 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 06/05/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident A's progress note dated February 21, 2017, (5 days after the orthopedic appointment), indicated the orthopedic doctor's clinic was called to get clarification on how long the dicloxacillin was supposed to be given. The document indicated not to start the medication until the orthopedic doctor talked to the pcp. Resident A's progress note dated March 1, 2017, (13 days after the orthopedic appointment), the orthopedic doctor was still unable to speak with Resident A's pcp. There was no documented evidence the pcp at the facility was notified and made aware of the need to speak to the orthopedic doctor so the antibiotic could be initiated for Resident A. Resident A's Medication Administration Record (MAR) dated March 1 to 27, 2017, for dicloxacillin to be given two times a day ( 9 a.m. and 5 p.m.), was reviewed and indicated the following: a. March 2 to 12, 2017, the antibiotic was given two times a day (9 a.m. and 5 p.m.); b. March 13, 2017, (9 a.m., was given, 5 p.m. had a code of 9); c. March 14, 2017 (9 a.m., coded 2, 5 p.m., coded 9); d. March 15 and 16, 2017 (9 a.m., was given, 5 p.m., coded as 9); e. March 17 and 18, 2017, (9 a.m., coded 2, and 5 p.m., was given); f. March 19, 2017, (9 a.m., coded 2 and 5 p.m., coded 9); FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X0JR11 Facility ID: CA240000091 If continuation sheet 19 of 32 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 06/05/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 g. March 20, 2017 (9 a.m., was given and 5 p.m., coded 9); and h. March 21, 2017, (9 a.m., was given). The MAR code indicated (9) meant other/ see nurse notes. Resident A's medication administration notes from March 2 to 26, 2017, were reviewed and indicated Resident A had refused the antibiotic on March 13, 14, 17, 18, and 19, 2017. There was no documented evidence whether Resident A's refusal was assessed for any reason, and an intervention was initiated to ensure Resident A would receive the antibiotic consistently. On March 27, 2017, at 11:10 a.m., the Director of Nursing (DON) was interviewed. He stated the nurses were expected to assess the reason for a resident's consistent refusal of medication.

F425 SS=D PHARMACEUTICAL SVC - ACCURATE PROCEDURES, RPH CFR(s): 483.45(a)(b)(1)

F425 06/20/2017 (a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. (b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-(1) Provides consultation on all aspects of the provision of pharmacy services in the facility; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X0JR11 Facility ID: CA240000091 If continuation sheet 20 of 32 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 06/05/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure appropriate pharmaceutical services was provided to ensure provision of routine medication (Harvoni- for chronic hepatitis) for one (Resident A) of three sampled residents. This failure had resulted in Resident A not to receive the medication for 6 months. Findings: On March 27, 2017, at 8:38 a.m, an unannounced visit to the facility was conducted to investigate a complaint related to quality care issues. On March 27, 2017, Resident A's record was reviewed. Resident A was admitted to the facility on August 15, 2016, with diagnoses which included type 2 diabetes mellitus (lifelong disease in which there is a high level of sugar in the blood). Resident A's physician order dated October 12, 2016, indicated an order for Harvoni tablet to be given once a day for chronic hepatitis C (viral disease that leads to swelling/ inflammation of the liver). Review of A's Medication Administration Record (MAR) dated October 1 to 31, 2016, was reviewed and indicated: a. October 13, 17, 22, 24, 25, 28, and 31, 2016, documented as (9); b. October 18, 19, and 20, 2016, documented as (5); and c. October 14-16, 21, 23, 26, 27, 29, and 30, 2016, documented with a check mark. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X0JR11 Facility ID: CA240000091 If continuation sheet 21 of 32 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 06/05/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 According to the MAR codes, the codes 9 meant other/ see nurse notes, 5 meant hold/see nurse notes, and check mark as administered. The medication administration notes dated October 13 to 31, 2016, were reviewed and indicated Resident A's Harvoni medication was being held due to pending authorization from the insurance and was unavailable. Resident A's MAR dated November 1 to 30, 2016, indicated: a. November 1, 7, 8, 13, 14, 16-19, 21, 27-30, 2016, were documented as given; and b. November 2-6, 9-12, 15, 20, 22, 24, 26, 2016, were documented (9). The medication administration notes dated November 1 to 30, 2016, were reviewed and indicated the Harvoni medication was pending insurance authorization (1 month after it was initially ordered). Resident A's December 1 to 31, 2016, (2 months after the Harvoni was initially ordered) MAR indicated: a. December 1, 2, 4, 6-9, 14, 17-20, 25, 26, 29, and 31, 2016, was documented with a check mark; b. December 3, 5, 10-13, 15, 16, 21, 22, 24, 27 -28, 2016, were documented as (9); and c. December 23, 2016, was documented as (5). The medication administration notes dated December 1 to 31, 2016, were reviewed and indicated Resident A's Harvoni was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X0JR11 Facility ID: CA240000091 If continuation sheet 22 of 32 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 06/05/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 unavailable, awaiting MD (medical doctor) clarification, awaiting liver biopsy (medical removal of tissue from a living subject to determine the presence or extent of a disease). Resident A's MAR dated January 1 to 31, 2017, (3 months after the Harvoni was initially ordered by the physician) indicated: a. January 1, 2, 4, 5, 10-13, 16, and 28, 2017, was documented as (9); b. January 3, 6-9, 14, 15, 20, 21, 26, 27, and 31, 2017, were documented with a check mark; and c. January 17-19, 22-24, 29-30, 2017, were documented as (5). The medication administration notes from January 1 to 31, 2017, indicated the Harvoni medication was held pending liver biopsy and awaiting authorization. Resident A's Medication Administration Record (MAR) dated February 1 to 28, 2017, (4 months after the medication was ordered by the physician), indicated: a. February 1 to 3, 5-8, 11, 13-14, 19-20, 2526, 2017, were documented with a check mark; b. February 4, 9, 12, 15-18, 21-24, 27-28, 2017, were documented as (9); and c. February 10, 2017, - was documented as (5). The medication administration notes dated February 1 to 28, 2017, were reviewed and indicated Harvoni medication was held due to unavailability, and pending authorization. Resident A's MAR dated March 1 to 27, 2017, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X0JR11 Facility ID: CA240000091 If continuation sheet 23 of 32 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 06/05/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 was reviewed and indicated the following: a. March 1-2, 5-8, 11-13, 17, 19, 24, 27, 2017, were coded 9; b. March 3-4, 9-10-14-16, 20-22, 20-23, 25-26, 2017, was coded with a checked mark. Resident A's progress notes dated March 1 to 26, 2017, were reviewed and indicated, "awaiting appt (appointment with ID (infectious disease) doc (doctor) for authorization "and "not available from pharmacy". The above documentation from October 2016 to March 2017, indicated Resident A's Harvoni was being held due to unavailability and was pending authorization from insurance since October 2016. There was no documented evidence a followup for insurance authorization to obtained Harvoni was initiated for Resident A. On March 27, 2017, at 10:25 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed. She stated Resident A's Harvoni was unavailable and was on hold pending pharmacy to deliver. LVN 1 stated she needed to follow-up with the pharmacy. On March 27, 2017, at 11:10 a.m., the Director of Nursing (DON) was interviewed. He stated if a medication could not be obtain from the pharmacy the nurses were supposed to notify the doctor regarding unavailability of the medication. The DON stated the nurses were expected to let him and the administrator knew for them to intervene regarding the unavailable medications. He stated he did not find documentation of any issues related to Resident A's Harvoni use from the pharmacy consultant. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X0JR11 Facility ID: CA240000091 If continuation sheet 24 of 32 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 06/05/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 March 27, 2017, at 12 p.m., the DON stated the information he gathered was since October 2016, Resident A had not receive Harvoni from the facility. On April 20, 2017, at 10:15 a.m., LVN 2 was interviewed. He stated if a medication was unavailable the nurses were expected to call the pharmacy to follow-up on delivery. LVN 2 stated the nurse was supposed to call the doctor to make them aware of unavailability of the medication. On May 2, 2017, at 8:54 a.m., the DON was interviewed and stated he could not find any pharmacy notes/reports which included Resident A's Harvoni use. On May 2, 2017, at 3:15 p.m., the Pharmacy Consultant was interviewed. He stated if there was any concern noted with medication availability, the pharmacy would communicate with nursing. The Pharmacy Consultant stated the concern regarding Resident A's Harvoni medication was communicated with one licensed nurse twice in the past. He stated the pharmacy failed to follow up the issue of medication unavailability with the DON and the administrator. The facility policy and procedure was reviewed. The policy titled, "Medication Regiment Reviews," revised April 2007, indicated, "...The Consultant Pharmacist shall review the medication regimen of each resident at least monthly...The primary purpose of this review is to help the facility maintain each resident's highest practicable level of functioning by helping them utilize medications appropriately and prevent or minimize adverse consequences related to medication therapy to the extent possible...As part of the MRR FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X0JR11 Facility ID: CA240000091 If continuation sheet 25 of 32 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 06/05/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 (medication regimen reviews), the Consultant Pharmacist will...Determine if the resident is receiving the correct medications as ordered...Identify medication errors, including those related to documentation...The Consultant Pharmacist will document his/her findings and recommendations on the monthly drug/medication regimen review report. 8. The Consultant Pharmacist will provide a written report to physicians for each resident with an identified irregularity. If the situation is serious enough to represent a risk to a person's life, health, or safety, the Consultant Pharmacist will contact the Physician directly to report the information to the Physician, and will document such contacts...The Consultant Pharmacist will provide the Director of Nursing Services and Medical Director with a written, signed and dated copy of the report, listing the irregularities found and recommendations for their solutions. 10. Copies of drug/medication regiment review reports, including physician responses, will be maintained as part of the permanent medical record..."

F514 SS=D RES RECORDSCOMPLETE/ACCURATE/ACCESSIBLE CFR(s): 483.70(i)(1)(5)

F514 06/20/2017 (i) Medical records. (1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X0JR11 Facility ID: CA240000091 If continuation sheet 26 of 32 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 06/05/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 (5) The medical record must contain(i) Sufficient information to identify the resident; (ii) A record of the resident’s assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician’s, nurse’s, and other licensed professional’s progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to maintain an accurate record of medication administration (Harvoni- for chronic hepatitis) for one (Resident A) of three sampled resident. This failure had resulted in records not to fully reflect whether Resident A was receiving treatment for chronic hepatitis (viral disease that leads to swelling/ inflammation of the liver) consistently which could cause the physician/ consulting physician not to be fully aware of the accurate medication regimen of Resident A. Findings: On March 27, 2017, Resident A's record was reviewed. Resident A was admitted to the facility on August 15, 2016, with diagnoses which included type 2 diabetes mellitus (lifelong disease in which there is a high level of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X0JR11 Facility ID: CA240000091 If continuation sheet 27 of 32 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 06/05/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 sugar in the blood). Resident A's physician order dated October 12, 2016, indicated an order for Harvoni tablet to be given once a day for chronic hepatitis C. Review of A's Medication Administration Record (MAR) dated October 1 to 31, 2016, was reviewed and indicated: a. October 13, 17, 22, 24, 25, 28, and 31, 2016, - documented as (9); b. October 18, 19, and 20, 2016, - documented as (5); and c. October 14-16, 21, 23, 26, 27, 29, and 30, 2016, - documented with a check mark. According to the MAR codes, the codes of 9 meant other/ see nurse notes, 5 meant hold/see nurse notes, and check mark as administered. Resident A's MAR dated November 1 to 30, 2016, indicated: a. November 1, 7, 8, 13, 14, 16-19, 21, 27-30, 2016, -were documented as given; and b. November 2-6, 9-12, 15, 20, 22, 24, 26, 2016- were documented (9). The medication administration notes dated November 1 to 30, 2016, were reviewed and indicated the Harvoni medication was pending insurance authorization (1 month after it was initially ordered). Resident A's December 1 to 31, 2016, (2 months after the Harvoni was initially ordered) MAR indicated: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X0JR11 Facility ID: CA240000091 If continuation sheet 28 of 32 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 06/05/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 a. December 1, 2, 4, 6-9, 14, 17-20, 25, 26, 29, and 31, 2016- was documented as given; b. December 3, 5, 10-13, 15, 16, 21, 22, 24, 27 -28, 2016 - were documented as (9); and c. December 23, 2016, -was documented as (5). The medication administration notes dated December 1 to 31, 2016, were reviewed and indicated Resident A's Harvoni was unavailable, awaiting MD (medical doctor) clarification, awaiting liver biopsy (medical removal of tissue from a living subject to determine the presence or extent of a disease). Resident A's MAR dated January 1 to 31, 2017, (3 months after the Harvoni was initially ordered by the physician) indicated: a. January 1, 2, 4, 5, 10-13, 16, and 28, 2017, was documented as (9); b. January 3, 6-9, 14, 15, 20, 21, 26, 27, and 31, 2017, were documented as given; and c. January 17-19, 22-24, 29-30, 2017, were documented as (5). The medication administration notes indicated the Harvoni medication was held pending liver biopsy and awaiting authorization. Resident A's Medication Administration Record (MAR) dated February 1 to 28, 2017, (4 months after the medication was ordered by the physician), indicated: a. February 1 to 3, 5-8, 11, 13-14, 19-20, 2526, 2017, - were documented as given; b. February 4, 9, 12, 15-18, 21-24, 27-28, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X0JR11 Facility ID: CA240000091 If continuation sheet 29 of 32 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 06/05/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 2017, - were documented as (9); and c. February 10, 2017, - was documented as held. The medication administration notes dated February 1 to 28, 2017, were reviewed and indicated Harvoni medication was held due to unavailability, and pending authorization. Resident A's MAR dated March 1 to 27, 2017, was reviewed and indicated the following: a. March 1-2, 5-8, 11-13, 17, 19, 24, 27, 2017, were coded 9; b. March 3-4, 9-10-14-16, 20-22, 20-23, 25-26, 2017, was coded with a checked mark. Resident A's progress notes dated March 1 to 26, 2017, were reviewed and indicated, "awaiting appt (appointment with ID (infectious disease) doc (doctor) for authorization"and "not available from pharmacy". On March 27, 2017, at 10:25 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed. She stated Resident A's Harvoni was unavailable and was on hold pending pharmacy to deliver. On March 27, 2017, at 12 p.m., the DON stated the information he gathered was since October 2016, Resident A had not receive Harvoni from the facility. The DON stated there should not be any documentation in the MAR that it was given. (MAR from October 2016 to March 2017 indicated there were days Harvoni was coded as given). On April 20, 2017, at 10:15 a.m., LVN 2 was interviewed. He stated if the medication was not given due to several reasons, the nurses FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X0JR11 Facility ID: CA240000091 If continuation sheet 30 of 32 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 06/05/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 were expected to document it not given, coded as (9). LVN 2 stated if coded as 9 then nurses should document in the nurses notes why the medication was not given. On April 25, 2017, at 10:31 a.m., LVN 3 was interviewed. She stated she had never received Harvoni for Resident A. LVN 3 stated she made a mistake in documenting the medication as given. She stated the appropriate code should have been (9) and documentation should have been noted in the nurses note as not given. On May 2, 2017, at 2:40 p.m., Resident A's MAR was reviewed with LVN 4. She aknowledged the multiple times she had documented Resident A having received the Harvoni medication from October 2016 to January 2017. LVN 4 stated she could have overlooked documenting that it (Harvoni) was given when the medication was unavailable to be administered to Resident A. She stated she should have corrected the administered entries when she knew the Harvoni medication was not provided to Resident A due to unavailability. The facility policy and procedure was reviewed. The policy titled, " Administering Medications," revised December 2012, indicated, "...Medications shall be administered in a safe and timely manner, and as prescribed...Medications must be administered in accordance with the orders, including any required time frame...if a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X0JR11 Facility ID: CA240000091 If continuation sheet 31 of 32 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 06/05/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: X0JR11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA240000091 (X5) COMPLETE DATE If continuation sheet 32 of 32