Inspection·December 4, 2024

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 one of three residents' (Resident 1) medication (Hydralazine-used to treat high blood pressure) was administered in accordance with the physician order. The medication was not held for systolic blood pressure (SBP-force of blood pumped out of the heart) below 110 per order. Residents Affected - Few This failure had the potential for Resident 1 to have low blood pressure requiring medical attention. Findings: On November 18, 2024, at 9:15 a.m., an unannounced visit was conducted to investigate a complaint on quality-of-care issue. On November 18, 2024, Resident 1 ' s record was reviewed. The record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included fusion of spine in lumbar (lower back) region, spinal stenosis (spaces inside the bones of the spine get too small), end stage renal disease (permanent condition that occurs when the kidneys stop functioning), dependence on renal dialysis (treatment that removes waste and excess fluid from the blood when kidneys are no longer functioning) and hypertensive heart disease (group of heart conditions that develop over time due to high blood pressure). A review of Resident 1 ' s Physician Orders dated October 10, 2024, indicated Hydralazine tablet, give one tablet by mouth three times a day for hypertension (condition in which the force of blood against the artery walls is too high), hold if SBP below 110 and heart rate below 60. A review of Resident 1 ' s Electronic Medication Administration Record (EMAR) indicated Hydralazine was administered on October 15, 2024, with a blood pressure (BP) of 101/78. On November 18, 2024, at 12:46 p.m., during an interview, Licensed Vocational Nurse (LVN)1 stated before administering blood pressure medications, the licensed nurse had to check the blood pressure of the resident. LVN 1 stated it was very important to follow parameters ordered by the physician to prevent any harm to the resident. On November 18, 2024, at 1:11 p.m., during an interview, LVN 2 stated the nurse had to check the BP before administering BP medication to a resident, especially if they had parameters ordered. LVN 2 stated it was important to follow orders for resident ' s safety. (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 2 Event ID: 555404 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 555404 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Village Healthcare Center 17040 Arnold Dr. Riverside, CA 92518 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)