Inspection·June 20, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an antihypertensive medication was held in accordance with the physician order for one of two sampled residents (Resident 1). In addition, the facility facility failed to ensure the physician was notified that Resident 1's antihypertensive medication was not administered in accordance with the physician order. Residents Affected - Few These failures had the potential to negatively affect the resident's medical condition. Findings: On July 19, 2025, at 10:36 a.m., during an interview, Resident 1 stated a nurse did not give her blood pressure (BP) medication last week. A review of Resident 1's admission Record, indicated she was admitted to the facility on [DATE], with diagnoses which included hypertension (HTN-high blood pressure). A review or Resident 1's History and Physical, dated May 5, 2025, indicated the resident had decision-making capacity. A review of Resident 1's Order Summary Report, dated June 19, 2025, indicated, Losartan Potassium-HCTZ (losartan-hctz – a BP medication) Tablet 50-12.5 MG Give 1 tablet by mouth one time a day for HTN Hold if SBP (systolic blood pressure) less than 110 or pulse less than 60 . was ordered on April 28, 2025. A review of Resident 1's Medication Administration Record (MAR), for the month of June 2025 indicated that on June 12, 2025, at 9:00 a.m., Resident 1's SBP was 119 and losartan was held due to vital signs outside of parameter. Further review of Resident 1's medical record indicated there was no documented evidence that Resident 1's physician was notified when LVN 1 held Resident 1's losartan-hctz. On June 19, 2025, at 1:39 p.m., during a concurrent interview with Licensed Vocational Nurse (LVN) 1 and record review of Resident 1's MAR for the month of June 2025, LVN 1 stated a resident's blood pressure was held depending on the parameter ordered by the physician and depending on the resident's condition. LVN 1 stated she would hold blood pressure medication when a resident SBP is less than 120 to avoid the resident's blood pressure to go low. LVN 1 stated she was familiar with Resident 1, and she held the losartan once last week because her SBP was less than 120. LVN 1 stated she did not want her blood pressure to drop. LVN 1 stated the physician's order was to hold Resident 1's (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 555017 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverwalk Post Acute 4000 Harrison Street Riverside, CA 92503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)