Health inspection·February 10, 2026

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the policy and procedure for Self-Administration of Medications was followed for one of six residents, (Resident 4).This failure had the potential for Resident 4 to overdose, have medications in an unsecured location, and staff to be unaware of the medications Resident 4 was taking. Findings:A review of Resident 4's medical records indicated Resident 4 was admitted on [DATE], with diagnoses of acute, (a serious condition that develops quickly without warning when the lungs can't get enough oxygen into the blood), and chronic, (a long-term condition in which the respiratory system is unable to adequately exchange oxygen and carbon dioxide in the body), respiratory failure, radiculopathy, (a pinched nerve, is the injury or damage to nerve roots in the spine where they exit the spinal column), lumbar region, chronic pain syndrome, acetonuria, (the presence of excessive amounts of ketone bodies in the urine indicating the body is breaking down fat for energy instead of glucose), and encounter for palliative care, (specialized medical care for people living with a serious illness, focused on relieving symptoms, pain, and stress to improve quality of life for both the patient and family).A review of Resident 4's History and Physical dated [DATE], indicated resident has the capacity to make decisions.On February 10, 2026, at 1:38 p.m., during an observation of Resident 4, Resident 4 was in bed with her call light within reach. The following medications were observed kept in two zippered cosmetic bags: acetaminophen, (to treat mild to moderate pain and reduces fever) 500 mg, melatonin, (commonly used as a short-term, over-the-counter supplement to treat insomnia) 10 mg, ZzzQuil PURE Zzzs Melatonin Gummies, non-habit-forming sleep aids), mucus relief, (acts as an expectorant to thin and loosen mucus in the airways), diphenhydramine (used to relieve allergy symptoms, hay fever, cold symptoms, and to aid sleep) 25 mg, ibuprofen 200 mg (a nonsteroidal anti-inflammatory drug (NSAID) used to relieve mild-to-moderate pain, reduce fever, and decrease inflammation), famotidine, reduces stomach acid production) 10 mg, docusate sodium, (stool softener used to relieve occasional constipation) 250 mg, potassium (used to prevent and treat low potassium) 99 mg, and Hair Skin and Nails vitamins (support the structural integrity and growth of these tissues by correcting nutrient deficiencies).On February 10, 2026, at 1:38 p.m., an interview was conducted with Resident 4. Resident 4 stated that she keeps her medications at the bedside and takes the medications as needed. Resident 4 stated that she takes docusate sodium 250 mg for constipation daily and the other medications as needed. Resident 4 stated that the ZzzQuil Pure ZZZs Melatonin Gummies she takes for sleep.On February 10, 2026, at 2:02 p.m., an interview was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated that Resident 4 was on her assignment for administering medications. LVN 1 stated that residents are not allowed to have medications at the bedside and would need to have a doctor's order for the medications.On February 10, 2026, at 4:21 p.m., an interview was conducted with LVN 2. LVN 2 stated that residents were not allowed to keep medications at the bedside. LVN 2 stated that if the resident had a Self-Administration Assessment completed and had Residents Affected - Few Page 1 of 4 555330 555330 02/10/2026 Riverside Postacute Care 8781 Lakeview Avenue Riverside, CA 92509

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a doctor's order to self-administer medications then the resident would be allowed to keep medications and administer the medications themselves.On February 10, 2026, at 4:28 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated that Resident 4 had an Assessment for Self-Administration of Medications dated February 3, 2026. The DON stated the medications that Resident 4 had at the bedside would have to be approved by the doctor. The DON was unaware that Resident 4 had medications that were not on the assessment and not ordered by the physician. The DON confirmed that acetaminophen 500 mg, melatonin 10 mg, ZzzQuil PURE Zzzs Melatonin Gummies, mucus relief, diphenhydramine 25 mg, ibuprofen 200 mg, famotidine 10 mg, potassium 99 mg, and Hair Skin and Nails vitamins, were not included on the Quarterly Risk Assessment dated February 3, 2026.On February 10, 2026, at 6:02 p.m., an interview was conducted with Resident 4. Resident 4 denied that she was required to keep a record or inform the nurse of the medications that she took.On February 10, 2026, at 6:05 p.m., an interview was conducted with LVN 3. LVN 3 stated that Resident 4 was on her assignment this shift 3-11 p.m. LVN 3 denied that Resident 4 was allowed to have medications at the bedside or was allowed to self-administer medications.On February 10, 2026, at 6:08 p.m., an interview was conducted with the Registered Nurse (RN). The RN stated that residents were not allowed to have medications at the bedside unless the resident had a doctor's order. The RN stated that the resident would have to inform the nurse that the medication was taken so they could document the medication on the Medication Administration Record.A review of Resident 4's Quarterly Risk Assessment dated February 3, 2026, indicated .J. Self Medication Administration Assessment1. Resident request self medication administration of medications Yes. 3. Nurse's Recommendations. 1. Can self-administer medication. 6. Bowel Care Medications Docusate Sodium Oral Tablet 100 MG1 tablet by mouth every 8 hours as needed.A review of Resident 4's Order Summary Report dated [DATE], indicated the following: -Acetaminophen Tablet 325 MG Give 1 tablet by mouth every 6 hours as needed for Fever > (greater than)100.2 F (Fahrenheit);-Acetaminophen Tablet 325 MG Give 1 tablet by mouth every 6 hours as needed for Mild pain (1-3); -Allergy Oral Tablet 25 MG (Diphenhydramine HCI) Give 1 tablet by mouth every 8 hours as needed for (allergies) (May self administer);-Docusate Sodium Oral Tablet 100 MG (Docusate Sodium) Give 1 tablet by mouth every 8 hours as needed for bowel management.A review of Resident 4's Order Summary Report dated [DATE], indicated the following:-Ibuprofen Oral Tablet 800 MG (Ibuprofen) Give 1 tablet by mouth every 6 hours as needed for Pain Management administer with/after meal or full glass of milk to prevent GI irritation.A review of the facility's policy and procedure titled, Self-Administration of Medications dated [DATE], indicated .The IDT considers the following factors when determining whether self-administration of medications is safe and appropriate for the resident:a. The medication is appropriate for self-administration;b. The resident is able to read and understand medication labels;c. The resident can follow directions and tell time to know when to take the medication;d. The resident comprehends the medication's purpose, proper dosage, timing, signs of side effectsand when to report these to the staff;e. The resident has the physical capacity to open medication bottles, remove medications from acontainer and to ingest and swallow (or otherwise administer) the medication; andf. The resident is able to safely and securely store the medication.For self-administering residents, the nursing staff determines who is responsible (the resident or thenursing staff) for documenting that medications are taken.7. If the resident is able and willing to take responsibility for documenting self-administration ofmedications, the resident is instructed on how to complete a record indicating the administration ofthe medication.8. Self-administered medications are stored in a safe and secure place, which is not accessible by otherresidents. If safe storage is not possible in the resident's room, the medications of residentspermitted to self-administer are stored on a central 555330 Page 2 of 4 555330 02/10/2026 Riverside Postacute Care 8781 Lakeview Avenue Riverside, CA 92509

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medication cart or in the medication room. Alicensed nurse transfers the unopened medication to the resident when the resident requests them.9. Any medications found at the bedside that are not authorized for self-administration are turned overto the nurse in charge for return to the family or responsible party.10. The facility reorders self-administered medications in the same manner as other medications.11. The nursing staff routinely checks self-administered medications and removes expired, discontinued, or recalled medications. 555330 Page 3 of 4 555330 02/10/2026 Riverside Postacute Care 8781 Lakeview Avenue Riverside, CA 92509

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 observation, interview, and record review, the facility failed to ensure call lights were answered in a timely manner when one of six residents (Resident 1), waited for 31 minutes for his call light to be answered when he wanted his briefs changed.This failure had the potential for Resident 1's needs to be unmet and experience possible skin breakdown due to wearing a wet brief for an extended period of time.Findings:A review of Resident 1's medical records indicated resident was admitted on [DATE], with diagnoses of cerebral infarction, (also known as a stroke, refers to damage to tissues in the brain due to a loss of oxygen to the area), hemiplegia, (paralysis of one side of the body), and hemiparesis, (weakness of one side of the body), following cerebral infarction affecting right dominant side, muscle wasting and atrophy, (wasting, thinning, or loss of muscle tissue, resulting in decreased size, strength, and movement capability), major depressive disorder, (a mood disorder that causes a persistent feeling of sadness and loss of interest), contracture, (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), right ankle, vascular dementia, (a decline in thinking skills caused by conditions that block or reduce blood flow to various regions of the brain), epilepsy, (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain), contracture, left ankle, foot drop, (weakness or paralysis of the muscles involved in lifting the front part of the foot), left and right foot, and schizophrenia, (a mental illness that is characterized by disturbances in thought).On February 10, 2026, at 10:02 a.m., an interview was conducted with Resident 1. Resident 1 stated that he used his call light when he needed to have a brief change or needed assistance. Resident 1 stated that he was unable to get out of bed without assistance. Resident 1 stated that call light response time was very slow and depended on who was working.On February 10, 2026, at 11:06 a.m., while at Resident 1's bedside, Resident 1 was observed pressing the call light, located on the right side of the bed. The call light illuminated in the room and outside above the doorway. While waiting for the call light to be answered, observed a staff member come into the room and assist the resident in C bed. Observed a housekeeper come into the room who did not address the call light. At 11:37 a.m., the Treatment Nurse (TN) came in and addressed the call light (31 minutes after Resident 1 pressed the call light).On February 10, 2026, at 11:38 a.m., an interview was conducted with the TN. The TN stated that all staff were responsible for answering call lights. The TN stated that the call light should be answered as soon as possible, and confirmed that 31 minutes was unacceptable.On February 10, 2026, at 12:04 p.m., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that she was assigned to Resident 1. CNA 1 stated that she was on a lunch break during the time Resident 1's call light was on. CNA 1 stated that all staff were responsible for answering call lights and they should be answered within five minutes.On February 10, 2026, at 1:33 p.m., an interview was conducted with the Housekeeper (HSKP). The HSKP stated that she cleans resident rooms on the unit. The HSKP stated that she can answer call lights.A review of the facility's policy and procedure titled, Answering the Call Light dated January 2018, indicated, The purpose of this procedure is to ensure timely responses to the resident's requests and needs .If the resident needs assistance, indicate the approximate time it will take for you to respond .If the resident's request requires another staff member, notify the individual .If the resident's request is something you can fulfill, complete the task within five minutes if possible. Residents Affected - Few 555330 Page 4 of 4