Inspection·October 14, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that Resident 1 received necessary care and services in accordance with the resident's comprehensive assessment and professional standards of practice when the facility did not conduct a comprehensive interdisciplinary assessment of transportation needs to ensure safe and proper transport to and from dialysis appointments for 1 of 3 sampled residents (Resident 1) reviewed for dialysis.This failure resulted in Resident 1 being transported to dialysis (medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to) appointments via Uber three times a week, leading to unsafe and uncomfortable transfers from wheelchair to car every dialysis appointment and resulted in missed or delayed dialysis on September 23 and 24, 2025, hospital transfer for dialysis, and continued use of an unsafe transport method. On October 2, 2025, while being transported in a standard vehicle (Uber), the resident sustained a right chest-wall hematoma, soft-tissue swelling, and possible rib fractures, demonstrating that the unsafe practice caused actual serious harm and placed the resident at ongoing risk of further injury or death. The facility continued to use Uber transportation for dialysis through October 9, 2025, after the resident's injury, thereby exposing the resident to an ongoing risk of serious injury or death from missed or delayed dialysis or additional trauma during unsafe transfers. This constitutes Immediate Jeopardy to resident health and safety because the facility's noncompliance caused actual serious harm and presented a continued likelihood of serious injury, harm, or death. On October 10, 2025, the ADM presented an acceptable removal plan which included the following:1. Resident 1 was assessed by assigned licensed nurse for any adverse effects of being transferred to dialysis using Uber Health (helps patients and clinical staff arrange and schedule transportation services with independent third-party providers) transportation.2. Resident 1 was also assessed by PT (Physical Therapist) to determine whether Resident 1 can tolerate the car or wheelchair van transportation.3. The Care Plan was updated to reflect current transportation information for dialysis.4. A new contract for wheelchair transport was drawn up by the ADM.5. An ad hoc (impromptu tasks, meetings, or projects that arise suddenly in response to a particular situation) QAPI (Quality Assurance and Performance Improvement - a data-driven and proactive approach used in healthcare facilities to systematically improve the quality of care provided to residents) Committee meeting was held to discuss changes in contracted dialysis transportation services.6. Inservice training was conducted by DON and/or DSD (Director of Staff Development) with licensed staff regarding use of contracted dialysis transportation.On October 14, 2025, at 2:07 p.m., the immediacy was removed in the presence of the ADM and the DON upon verification of implementation of the removal plan.Noncompliance for F684 remained at the scope and severity of J actual harm that is immediate jeopardy to resident health and safety.Findings:A review of Resident 1's admission Record dated October 3, 2025, indicated Resident 1 was initially admitted to the facility on [DATE], with diagnoses which included type 2 diabetes (high blood sugar), end stage renal disease (permanent kidney failure that requires a regular course of dialysis).A review of Resident 1's Physical Therapy Evaluation and Plan of Treatment, dated September 18, 2025, indicated, .Precautions: fall risk .heel WB (weight bearing) only during transfers .S/P (status after) amputation (removal of the body part) of L (left) 2nd and 3rd toes .A review of Resident 1's Minimum Data Set (MDS - a standardized assessment tool) dated September 22, 2025, indicated the resident is cognitively intact (ability to think effectively) and requires substantial/maximal assistance with sit to stand and chair/bed-to-chair transfer and dependent with wheelchair mobility. A review of Resident 1's Order Summary Report dated October 3, 2025, indicated .Dialysis Center: (name, Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555330 If continuation sheet Page 2 of 6 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 555330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Postacute Care 8781 Lakeview Avenue Riverside, CA 92509 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)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few address and telephone number) Dialysis Days: T-Th-Saturday (Tuesday-Thursday-Saturday) Pick-up time 0415 (4:15 a.m.) chair time 0430 (4:30 a.m.) . was ordered on September 18, 2025.A review of Resident 1's Progress Notes indicated the following:-On September 23, 2025, at 6:30 a.m., Resident 1 missed her dialysis appointment due to transportation. No further explanation was documented.-On September 23, 2025, at 4:58 p.m., the SSD wrote she was informed Resident 1 missed dialysis due to transportation not arriving and she reached out to the transportation who stated that they are no longer transporting Resident 1 due to non-payment from the facility. The SSD reached out to the corporate office regarding non-payment, and she was informed that Resident 1's transportation needs to be provided by a straight Medi-cal (a type of health insurance plan) provider.-On September 24, 2025, at 6:38 a.m., Resident 1 missed the rescheduled dialysis appointment today due to transportation issues. At 9:27 a.m., the resident was transferred to the GACH and at 11:10 p.m., the resident returned to the facility after receiving dialysis.-On September 30, 2025, Resident 1 was picked up by Uber and accompanied by a (Certified Nursing Assistant) CNA.-On September 30, 2025, at 11:59 a.m., Resident 1 returned from her dialysis appointment at 11:45 a.m., with CNA escort via Uber.-On October 4, 2025, at 12:33 a.m., the Licensed Vocational Nurse (LVN) was notified that Resident 1 had large bruising on her right torso and small discoloration to her left underarm. The area was assessed, and discoloration and slight inflammation were noted. Resident 1 stated she had trouble getting into the transportation for dialysis and she got hurt. Resident 1's MD (Medical Doctor) and FM (family member) were notified.-On October 4, 2025, at 12:46 at 2:39 a.m., Resident 1 was transferred out to the GACH for the discoloration of her right torso.A review of Resident 1's IDT (Interdisciplinary Team - a group of healthcare professionals from different disciplines who collaborate to provide comprehensive and coordinated care for a patient) Care Conference with a review date of October 1, 2025, indicated that Resident 1's FM expressed concerns regarding dialysis transportation. It was explained to him that the facility has been paying for transportation and has not been authorized to schedule a wheelchair van, that is why the resident goes to dialysis via Uber.On October 3, 2025, at 10:14 a.m., during a concurrent observation and interview, Resident 1 was sitting in her wheelchair on the smoking patio and was wheeled by a staff member to the family room. Resident 1 stated she goes to dialysis three times a week on T-Th-Sat and leaves the facility at 3:30 a.m. Resident 1 stated the Social Service Director (SSD) quit paying her insurance to get her van transportation. Resident 1 stated the facility has been putting her in an Uber car and it is uncomfortable and awfully hard for her. Resident 1 stated the facility nurses transferred her to the car, but it's wrong and she should be going in a wheelchair van. Resident 1 stated the last time she had dialysis, she was at the dialysis center until 7:30 a.m., because the facility had to send a larger Uber car which took more time. Resident 1 stated she doesn't want to take Uber anymore because she may end up breaking a bone.On October 3, 2025, at 11:37 a.m., during a telephone interview with the Unit Secretary (US) of (name of dialysis center), she stated there had been issues with Resident 1's transportation and it started when her insurance changed. Initially, the facility transported Resident 1 to the dialysis center via Uber by herself and the dialysis staff had to transfer Resident 1 out of the car to her wheelchair. The US stated they requested for the facility to provide a staff member because according to the dialysis center's policy the dialysis staff cannot transfer residents from car to chair. The facility then provided staff to go with Resident 1 during her dialysis appointments. The US stated Resident 1 missed dialysis appointments in August and September 2025, due to a mix of transportation issues and her refusing to go to dialysis. The US stated the facility should have provided wheelchair van transportation for the resident.On October 3, 2025, at 11:41 a.m., during an interview, LVN 1 stated the SSD arranged (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555330 If continuation sheet Page 3 of 6 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 555330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Postacute Care 8781 Lakeview Avenue Riverside, CA 92509 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)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few non-emergency medical transportation for dialysis residents.On October 3, 2025, at 1:08 p.m., during an interview, the SSD stated dialysis residents are admitted to the facility with transportation and dialysis appointments already arranged and that she arranged transportation for any make up dialysis days. The SSD stated Resident 1's insurance is accepted by very few transportation companies. The SSD stated they were using a private wheelchair van transportation for Resident 1, but the facility stopped paying and she does not know why. The owner of the private wheelchair van transportation informed her that because he was not getting paid, he could not take Resident 1 to dialysis anymore. The SSD stated the Case Manager (CM) arranged recurrent trips for Resident 1's dialysis appointments via Uber which started the week of September 22, 2025. The SSD stated this was not discussed with Resident 1 nor her FM. The SSD stated it was the corporate office who determined to use Uber because they did not want to pay for wheelchair van transportation. The SSD stated if the resident's insurance does not cover transportation, the resident can pay privately, and if the resident cannot pay, the facility will pay for it.On October 3, 2025, at 2:49 p.m., during an interview, the DON stated the SSD coordinated the transportation. The DON stated non-emergent transportation should be provided by the facility to the residents including dialysis transportation. The DON stated that the corporate office told them to provide Uber transportation for Resident 1.On October 3, 2025, at 4:23 p.m. during a telephone interview with Resident 1's FM, the FM stated the facility was sending Resident 1 to her dialysis appointments via Uber. The FM stated Resident 1 had an operation on her feet and was not supposed to put pressure on her feet and that she needed a lifted van for a wheelchair transfer. The FM stated he had a meeting with the facility on October 1, 2025, and they said they would take care of the transportation, but he did not hear from them.On October 3, 2025, at 5:17 p.m., during a telephone interview, Registered Nurse (RN) 1 stated that there was an occasion when the transportation did not show up for Resident 1 and she informed the SSD. The SSD informed her it was an insurance thing. RN 1 stated Resident 1 is now going to dialysis via Uber with two CNAs, but the CNAs are stating they have trouble transferring her into the car. RN 1 stated Resident 1 used to have a wheelchair van that picked her up. RN 1 stated it was better and safer for Resident 1 to be transported in a wheelchair van than Uber.On October 6, 2025, at 2:53 p.m., during a telephone interview, RN 2 stated, on September 23, 2025, the transportation for Resident 1 did not show up and her dialysis appointment was rescheduled for the next day, September 24, 2025. On September 24, 2025, an Uber picked up Resident 1 to go to her dialysis appointment and she went by herself. When she arrived at the dialysis center, she did not get her dialysis treatment because she was in an Uber. RN 2 stated that it was the first time she had seen an Uber pick up Resident 1. RN 2 stated Uber was absolutely not an appropriate transportation for Resident 1 because it was hard for her to go in and out of the Uber and she needed help.On October 9, 2025, at 10:30 a.m., during an observation, Resident 1 was in her room, lying in bed and asleep, CNA 1 was sitting at the bedside. CNA 1 stated the resident returned from dialysis that morning between 7:30 a.m. to 8:00 a.m. CNA 1 stated two CNAs went with Resident 1 for her dialysis appointment via Uber.On October 9, 2025, at 10:39 a.m., during an interview, CNA 2 stated she started taking Resident 1 to her dialysis appointments on October 2, 2025, via Uber. CNA 2 stated another CNA helped her transfer Resident 1 into Uber. CNA 2 stated Resident 1 can stand with two-person assistance, and she is basically deadweight (a person who is physically unable to assist with their own movement). CNA 2 stated Resident 1 disliked Uber and she informed the SSD and the RN about it. CNA 2 stated Resident 1 kept calling her FM and told him he needed to pay for gurney transportation (catered to patients with limited mobility or require a stretcher to be moved) and that she got mad because her FM could not pay for it.On October 9, 2025, at 11:27 a.m., during an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555330 If continuation sheet Page 4 of 6 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 555330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Postacute Care 8781 Lakeview Avenue Riverside, CA 92509 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)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few interview with the Director of Rehabilitation (DOR), she stated that Resident 1 did not have a weight-bearing status order from the GACH physician. However, due to her toe amputation, they placed her on heel weight-bearing status to allow wound healing. The DOR mentioned that their department was not consulted to assess Resident 1's transportation needs, which is typically their responsibility. On October 3, 2025, Resident 1 received car transfer training by two rehabilitation staff using a staff member's car.On October 9, 2025 at 12:31 p.m., during a follow-up interview, CNA 2 stated that on October 2, 2025, Resident 2 was leaning on her left side and was agitated during the Uber ride because her FM couldn't pay the wheelchair van transportation.On October 9, 2025, at 12:39 p.m., during a follow-up interview, the SSD stated she did not consult the rehabilitation or nursing departments before using Uber because the CM initiated it. She contacted rehabilitation on October 2, 2025, after speaking to Resident 1's FM. Despite this, Resident 1 continues to use Uber for dialysis appointments as the corporate office would not cover wheelchair van costs. The SSD emphasized that the facility is responsible for providing appropriate transportation for Resident 1 and meeting all her care needs.On October 9, 2025, at 12:56 p.m., during an interview, LVN 2 stated on October 3, 2025, during shift change, he received a report from a CNA that Resident 1 had a bruise on the right side of her torso, and he created a change of condition (recording any major or minor change in a resident's health status). LVN 2 stated he found out the next day that Resident 1 was transferred out to the GACH.On October 9, 2025, at 1:33 p.m., during a telephone interview, the Case Manager (CM) indicated that she arranged Resident 1's transportation to the dialysis center using Uber Health. The CM mentioned that she did not consult the rehabilitation or nursing department prior to booking the Uber, as she was following specific instructions. According to the CM, the Administrator (ADM) directed her to organize the Uber for Resident 1's dialysis appointments.On October 9, 2025, at 2:16 p.m., during an observation, Resident 1 was sitting in her wheelchair, with a smoking apron on, smoking a cigarette in the smoking patio, with a 1:1 sitter (a designated staff member who provides constant, one-to-one observation and care) nearby.On October 9, 2025, at 2:30 p.m., during an interview with Resident 1 in the family room, Resident 1 stated she did not like Uber because the cars that arrived were either too small or too high which was hard for her to get into. Resident 1 stated she was transferred into the car by the CNAs who put their arms under her armpits and scoot her backwards into the car.On October 9, 2025, at 3:17 p.m., during an interview, the Physical Therapist Aid (PTA) stated they were asked to conduct car transfer training with Resident 1 and the CNAs, but not an assessment to determine an appropriate mode of transportation. The PTA stated Resident 1 can transfer from bed to wheelchair and vice versa with two-person physical assistance, meaning she can transfer anywhere as long as there are two people helping her. The PTA stated it was the facility who decided to use Uber for Resident 1.On October 9, 2025, at 3:57 p.m., during an interview, the DON stated Resident 1 was transferred to the hospital because of her bruises. The DON stated that according to CNA 2, Resident 1 was getting agitated and was trying to get out of her seatbelt while they were inside the Uber and they sent her to the hospital for evaluation.On October 9, 2025, at 4:40 p.m., during a follow up interview with the DON, the DON was asked if she knew that Resident 1 disliked Uber. The DON stated she heard about it on October 3, 2025, when they found out about the bruises. The DON stated she does not have an answer when she was asked why Resident 1 was still going to her dialysis appointments via Uber.On October 9, 2025, at 4:56 p.m., during an interview, the ADM stated Resident 1 was going to dialysis via Uber with two CNAs for safety. The ADM stated the facility began paying for Resident 1's Uber transportation when her insurance changed and a decision was made to stop using the prior transportation, and he does not know why. The ADM stated they were having problems getting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555330 If continuation sheet Page 5 of 6 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 555330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Postacute Care 8781 Lakeview Avenue Riverside, CA 92509 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)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete transportation that's reliable to come to the facility at 4:00 a.m. When asked if it was acceptable to transport a resident by Uber without first determining the appropriate mode of transportation, the ADM stated that doing so poses a risk or injury to the resident compared to a wheelchair van transportation.A review of Resident 1's GACH records titled, Physician Chart dated October 4, 2025, indicated Resident 1 arrived at the Emergency Department at 1:34 a.m., and on physical examination Resident 1 had bruising on the right and left side of her torso, between the lowest rib and the hip, with mild tenderness when touched.A review of Resident 1's Computed Tomography (CT) Scan (a diagnostic imaging test that created detailed pictures of the inside of the body) of the chest dated October 4, 2025, indicated Resident 1 had right breast and chest muscle hematoma (localized collection of blood) and soft tissue swelling, side right chest wall subcutaneous (under the skin) soft tissue swelling probable contusion (bruise), possible nondisplaced lateral right rib fractures (a type of bone fracture where the broken bone pieces remain in their original position).A review of the facility's policy titled, Transportation, Social Services dated January 2018, indicated .Our facility shall help arrange transportation for residents as needed .Social services will help the resident as needed to obtain transportation . Event ID: Facility ID: 555330 If continuation sheet Page 6 of 6