Inspection·December 19, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and hemiparesis (muscle weakness or paralysis affecting one side of the body the arm, leg, and facial muscles) left non-dominant side. A review of Resident A's care plan, revised on July 16, 2024, indicated, .Resident requires assistance from staff for bed mobility related to weakness and decreased strength. Unable to turn and reposition self in bed without physical assistance from staff . A review of Resident A ' s Minimal Data Set (MDS- a federally mandated resident assessment tool), dated November 11, 2024, indicated, .Functional Abilities-sit to stand, chair/bed to chair transfer, and tub/shower transfer all .Dependent-helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity . A review of Resident A ' s Progress Note, dated December 8, 2024, at 4 p.m., indicated, .patient reported to attending .she is experiencing pain over rt. (right) shoulder area .also reported pain over left hip area .per patient ' s account the pain started after staff member moved her on the edge of the bed grabbing her rt (right) shoulder and moving her left lower extremity (leg) forcibly over the edge of the bed on 12-6-24 (December 6, 2024) at night time . On December 17, 2024, at 4:29 p.m., an interview was conducted with the DON. The DON stated according to CNA 1, she was trying to get Resident A from the bed to the shower chair, was unable to get Resident A up, and provided bed bath instead. The DON stated the police spoke with all three CNAs on shift the night of the incident on December 6, 2024, the CNAs told the police CNA 1 did not ask for help with Resident A during the evening shift, and CNA 1 stated she did not use the mechanical lift for Resident A. On December 18, 2024, at 8:50 a.m., an interview was conducted with the RN. The RN stated it is best to get two persons to assist for safety when transferring a resident. The DSD stated it is always best to consult the chart and/or the therapy department for recommendations if a resident ' s transfer ability is not known. The RN stated Resident A needed two person assistance to get up. On December 2024, at 10:25 a.m., an interview was conducted with the Director of Staff Development (DSD). The DSD stated she encourages the CNAs to walk room to room and give report, if a staff member does not know how to transfer a resident, they should ask a nurse or another CNA who has had the resident before, residents do not always know what their true ability is. The DSD stated she requires the nursing staff to have a partner when using the mechanical lift in transferring the resident for safety. On December 18, 2024, at 11:40 a.m., an interview was conducted with CNA 2. CNA 2 stated she was working the PM shift (3 p.m. to 11 p.m.) on December 6, 2024, and she did not have Resident A that evening. CNA 2 stated CNA 1 was assigned to Resident A, and CNA 1 did not ask for help to move or transfer Resident A. CNA 2 stated she has been Resident A ' s CNA before and she always gets someone to assist her if she needs to move or transfer the resident, she does not think Resident A is able to stand very well, and when moving Resident A she uses the mechanical lift for the most part. CNA 2 stated she is small and because of her size she was not able to move Resident A without assistance. CNA 2 stated Resident A had a lot of weakness on her one side, and for the safety of the resident two people are needed. A review of the facility ' s policy titled Activities of Daily Living (ADLs), Supporting, dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555404 If continuation sheet Page 2 of 3 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 12/19/2024 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm March 2018, indicated .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently .appropriate support and assistance with .Mobility (transfer and ambulation .A resident ' s ability to perform ADLs will be measured using clinical tools, including the MDS .Interventions to improve or minimize a resident ' s functional abilities will be in accordance with the resident ' s assessed needs, preference, stated goals and recognized standards of practice . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555404 If continuation sheet Page 3 of 3