Health inspection·June 2, 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 observation, interview, and record review, the facility failed to ensure the necessary care and treatment was provided, for one of five sampled residents (Resident 4), when: Residents Affected - Some 1. Resident 4 ' s left forehead laceration was not evaluated and referred to a physician for suture removal. This failure had the potential for the delay in necessary care and treatment of possible complications related to skin injuries/problems; 2. Resident 4 ' s blood sugar level was not monitored after the insulin medication was discontinued on March 13, 2025. This failure had potential for Resident 4 ' s blood sugar level to be inadequately control which could alter the resident's mental status and affect the resident's overall health condition. 3. Resident 4 ' s baseline weight was not obtained timely after admission on [DATE]. This failure had the potential for the delay in necessary care and further complications of malnourishment; 4. Resident 4 ' s change of condition (COC) of low blood pressure was not relayed to a physician for appropriate management. This failure has the potential to result in deterioration of Resident ' s 4 health condition; and 5. Resident 4 ' s oral care after meals was not provided on March 27, 2025. This failure had the potential to cause serious health issues and could affect Resident ' s psychosocial well-being. Findings: On May 29, 2025, at 8 a.m., an unannounced visit was conducted to the facility for the investigation of a complaint regarding quality of care and treatment. 1. On May 29, 2025, Resident 4 ' s record was reviewed. Resident 4 was admitted to the facility on [DATE], with diagnoses which included encephalopathy (brain disorder) and sepsis (blood infection). A review of Resident 4 ' s History and Physical, dated March 2, 2025, indicated Resident 4 was mentally incapable of understanding. A review of Resident 4's BODY CHECK, dated March 13, 2025, indicated, .Pt (patient) returned to facility with laceration to L (left) forehead measuring 4.5 x (by)1.0 cm. (centimeter-unit of measurement) with 6 sutures . Page 1 of 8 555404 555404 06/02/2025 Riverside Village Healthcare Center 17040 Arnold Dr. Riverside, CA 92518

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 4's Order Summary, dated March 13, 2025, indicated, .L (left) forehead laceration-clean with ns (normal saline), pat dry, apply betadine, leave OTA (open to air) every day shift for 14 days . A review of Resident 4's Care Plan Report, dated March 14, 2025, indicated, .Surgical Wound .Lt (left) forehead laceration, 6 sutures .Provide skin care .Treatment as ordered, notify MD . A review of Resident 4's WEEKLY SKIN ALTERATION REPORT, dated March 18, 2025, indicated the following: - Resident 4 ' s left forehead with six (6) surgical sutures has no drainage, peri wound was dry with quality 90% epithelial tissue (wound's progression towards healing and restoration) and 10% scab, and; - Resident 4 ' s current treatment orders indicated, . weekly assessment of Lt forehead wound .Sites Healing . A review of Resident 4's acute hospital records titled, Daily Focus Assessment Report, dated March 27, 2025, indicated, .Removed stiches from patients forehead that were placed by (name of hospital) on March 12, 2025 . On May 29, 2025, at 11:25 a.m., during a concurrent interview and record review with the Treatment Nurse (TN), the TN stated there was no wound and suture evaluation conducted on the fourth week stay of Resident 4 and was not relayed to a physician. The TN stated the healing surgical wound with suture should have been reported to the physician. The TN stated the suture should have been removed to prevent complications such as overgrowth or the skin and could lead to skin irritation and infection. The TN further stated if the surgical wound would not be evaluated and reported, the skin condition would fall through the cracks. On June 2, 2025, at 2:45 p.m., during an interview with the Director of Nursing (DON), the DON stated she expected to the nurses follow the procedure guidelines for wound care. The DON stated the surgical wound with sutures should have been monitored and relayed to a physician. The DON further stated the healed wound with sutures should have been evaluated and should have been removed to prevent complications such as skin irritation and infections. A review of the facility's policy and procedure titled, Staple and Suture Removal, dated September 2013, indicated, .The purpose of this procedure is to provide guidelines for the removal of staples or sutures from a healing wound .Review the resident ' s care plan, current orders, and diagnoses to determine if there are special residents needs .Report other information in accordance with facility policy and professional standards of practice . 2. On May 29, 2025, Resident 4 ' s record was reviewed. Resident 4 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus II (DM II-abnormal blood sugar). A review of Resident 4 ' s Order Summary, dated March 1, 2025, indicated, .glipiZIDe Oral Tablet 10 MG (Milligram-unit of measurement) .Give 1 tablet by mouth two times a day for DM II; Give with meals . A review of Resident 4's Care Plan Report, dated March 2, 2025, indicated, .Risk for 555404 Page 2 of 8 555404 06/02/2025 Riverside Village Healthcare Center 17040 Arnold Dr. Riverside, CA 92518

F 0684 Level of Harm - Minimal harm or potential for actual harm hypo/hyperglycemia (low/high blood sugar level) secondary to: Diabetes Mellitus .Test the resident ' s blood glucose (sugar) .Blood sugar check as ordered .Monitor for s/s (signs and symptoms) low blood sugar .Monitor for s/s of high blood sugar . A review of Resident 4 ' s Lab Results Report, indicated the following: Residents Affected - Some - March 18, 2025, glucose 176, high, and: - March 23, 2025, glucose 154, high. A review of Resident 4 ' s Blood Sugar Summary, dated March 2025, indicated, Resident 4 ' s last blood sugar level was 107 mg/dL (milligrams per deciliter) was documented on March 13, 2025, and no documentation of Resident 4's blood sugar continued after March 13, 2025. On May 29, 2025, at 11:30 a.m., during a concurrent interview and record review with the Registered Nurse (RN), the RN stated Resident 4 ' s insulin was discontinued on March 4, 2025, and she did not clarify to a physician if the blood sugar check would be continued. The RN stated Resident 4 ' s blood sugar level should have been checked and should have been monitored to prevent complications of diabetes. The RN further stated if Resident 4 ' s blood sugar level would not be monitored, it could alter mental status and potentially lead to hospitalization. On June 2, 2025, at 2:45 p.m., during an interview with the DON, the DON stated she expected for the nurses to follow the facility ' s policy and procedure for diabetes management. The DON stated Resident 4 ' s blood sugar level should have been monitored and checked to prevent complications. The DON further stated if blood sugar would not be monitored it would lead to serious condition such as diabetic coma or shock. A review of the facility's policy and procedure titled, Diabetes-Clinical Protocol, dated November 2020, indicated, .As indicated, the Physician will order appropriate lab tests .and adjust treatments based on results and other parameters .Examples of blood glucose monitoring for various situations might include the following: (1) For the resident on oral medication(s) who is well controlled: monitor blood glucose level at least twice a weekly .(3) For resident receiving insulin who is well controlled: monitor blood glucose levels twice a day . 3. On May 29, 2025, Resident 4 ' s record was reviewed. Resident 4 was admitted to the facility on [DATE], with diagnoses which included muscle waiting and atrophy (loss of muscle mass). A review of Resident 4 ' s Order Summary, dated March 1, 2025, indicated, .Fortified diet .for Nutrition . A review of Resident 4 ' s 12 MINI NUTRITIONAL ASSESSMENT, dated March 1, 2025, indicated, Resident 4 has a score of 5 with a category of malnourished. A review of Resident 4 ' s Care Plan Report, dated March 1, 2025, indicated, .NUTRITIONAL RISK .Monitor weight and notify MD for any undesirable weight changes .Refer for dietary/RN (Registered Dietician) consult . A review of Resident 4 ' s Weight Summary, dated March 2025, indicated the following: 555404 Page 3 of 8 555404 06/02/2025 Riverside Village Healthcare Center 17040 Arnold Dr. Riverside, CA 92518

F 0684 - March 3, 2025, 109 lbs. (pounds - unit of measurement); Level of Harm - Minimal harm or potential for actual harm - March 11, 2025, 107 lbs; - March 19, 2025, 105 lbs; and Residents Affected - Some - March 25, 2025, 101 lbs. On May 29, 2025, at 11:30 a.m., during a concurrent interview and record review with the Restorative Nursing Assistant (RNA), the RNA stated Resident 4 was admitted on [DATE], and she took the weight on March 3, 2025. The RNA stated Resident 4 ' s weight should have been taken upon admission or the next day so it would be reported to the nurse the accurate weight of resident upon admission. The RNA further stated it was two days delayed. On May 29, 2025, at 11:30 a.m., during a concurrent interview and record review with the RN, the RN stated Resident 4 ' s weight should have been taken upon admission or the next day so the nurses could identify if there was a need to notify a dietician regarding nutritional management. The RN stated if there was a delay of obtaining weight, it would potentially result to a further weight loss. On June 2, 2025, at 2:45 p.m., during a follow up phone interview with the DON, the DON stated she expected the staff follow policy and procedure of weight loss management. The DON stated Resident 4 should have been weighed upon admission or the next day of admission. The DON further stated if weight would not be obtained timely, there was a potential delay of care to Resident 4. A review of the facility's policy and procedure titled, Weight Assessment and Intervention, dated September 2008, indicated, .The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents .The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter . 4. On May 29, 2025, Resident 4 ' s record was reviewed. Resident 4 was admitted to the facility on [DATE], with diagnoses which included hypertension (HTN - elevated blood pressure). A review of Resident 4 ' s Order Summary, dated March 1, 2025, indicated, Carvedilol (medication to treat hypertension) Oral Tablet 3.125 MG .Give 1 tablet by mouth one time a day for HTN . A review of Resident 4's Care Plan Report, dated March 2, 2025, indicated, .Hypertension .Resident will maintain clinically acceptable range of blood pressure .Monitor BP and refer to MD for changes . A review of Resident 4 ' s Blood Pressure Summary, dated March 2025, indicated the following: - March 26, 2025, at 21:59 p.m., 64/47 mmHG (unit of measurement), BP-low; - March 27, 2025, at 00:11 a.m., 94/56 mmHg, BP (low_; and - March 27, 2025, at 00:42 a.m., 106/59 mmHg, BP (low.) A review of Resident 4 ' s Nurse ' s Note, dated March 27, 2025, indicated, Vital signs for resent (sic) rechecked due to CNA advising this writer that resident had a low blood pressure. Using an arm 555404 Page 4 of 8 555404 06/02/2025 Riverside Village Healthcare Center 17040 Arnold Dr. Riverside, CA 92518

F 0684 cuff blood pressure rechecked at 0042 with BP reading 106/59 . Level of Harm - Minimal harm or potential for actual harm On May 29, 2025, at 11:30 a.m., during a concurrent interview and record review with the RN, the RN stated Resident 4 ' s blood pressure of 106/59 on March 27, 2025, was low and there was no evidence of documentation of change of condition and the physician was not notified. The RN further stated if a physician would not be notified of the change of condition of a resident, it could result to conditions such as alteration of mental state, shock (life threatening condition where the body experiences insufficient blood flow) and could passed out. Residents Affected - Some On June 2, 2025, at 2:45 p.m., during an interview with the DON, the DON stated she expected all the nurses to follow the facility ' s policy and procedure for a resident ' s change of condition and blood pressure management. The DON stated a physician should have been notified of Resident 4 ' s change of condition. The DON further stated if physician was not notified and no COC, Resident 4 ' s could potentially increase her health deterioration. On June 3, 2025, at 8:56 a.m., during an interview with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 4 ' s blood pressure was low when he manually rechecked it with blood pressure cuff on March 27, 2025, at 00:42 in the morning. LVN 1 stated Resident 4 ' s change of condition was not relayed to the attending physician. LVN 1 stated Resident 4 ' s low blood pressure should have been identified as COC and should have been reported to a physician. LVN 1 further stated if COC not reported to a physician, resident could deteriorate and declined health condition. A review of the facility's policy and procedure titled, Blood Pressure, Measuring, dated September 2010, indicated, .The purpose of this procedure is to measure the pressure exerted by the circulating volume of blood .Hypotension is defined as blood pressure less than 100/60 mm/Hg .Hypotension should be reported to the physician . A review of the facility's policy and procedure titled, Change in a Resident ' s Condition or Status, dated May 2017, indicated, .Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident ' s medical/mental condition and/or status .Prior to notifying the Physician .the nurse will make detailed observations and gather relevant and pertinent information .including (for example) information prompted by the Interact SBAR Communication Form . 5. On May 29, 2025, Resident 4 ' s record was reviewed. Resident 4 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss), encephalopathy (condition where brain function is impaired), gastro-esophageal reflux disease (stomach acid flows back and cause heartburn) and muscle wasting. A review of Resident 3's Minimum Data Set (MDS - an resident assessment tool), dated March 7, 2025, indicated the following: - Resident 3 had a Brief Interview for Mental Status (BIMS - a cognitive assessment) score of 06 (severe cognitive impairment); - Resident 3 required totally dependent with oral hygiene; and - Resident 3 would hold food in her cheeks after a meal, and had difficulty swallowing food. 555404 Page 5 of 8 555404 06/02/2025 Riverside Village Healthcare Center 17040 Arnold Dr. Riverside, CA 92518

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 3's Physician Orders, dated March 1, 2025, indicated Resident 3 had an appointment to a pain clinic on March 27, 2025, at 9:30 a.m. A review of Resident 3's care plan, dated March 6, 2025, indicated, .ADL (Activities of Daily Living) functioning with self-care deficit .requires total assistance in personal hygiene .dental/oral care PRN (as needed) .: On May 29, 2025, at 10:20 a.m., an interview was conducted with the RNA. The RNA stated the staffs should be watchful while feeding residents, residents should be fed very slowly, check and feel residents ' cheeks and ensure the residents were able to tolerate the food. The RNA stated oral care must be provided to the residents after each meal and before bed. The RNA stated they used clean cloth dip in warm water to clean all surrounding cheeks, upper and lower lips, and teeth to remove anything that could have been stuck. On May 29, 2025, at 11:30 a.m., during an interview with the RN, the RN stated the CNAs (Certified Nursing Assistants) do oral care on residents with feeding issues, immediately after meals and before bed. On May 29, 2025, at 12:57 p.m., an interview and concurrent document review conducted with the Food and Nutritional Service Director (FNSD), the FNSD reviewed menu from March 26 and 27, 2025 and the Cook's spreadsheet. The FNSD stated Resident 4 received dinner March 26, 2025, which included a soft diet with green beans soft, cheese ravioli garlic bread soft, soft ripe and no skin. The FNSD stated for breakfast on March 27, 2025, included egg soft fried, oats softened in milk, and soft hash browns. The FNSD stated Resident 4 was assigned with a 1:1 feeding assistant. The FNSD further stated Resident 4 did have holding of food in mouth and cheeks noted in MDS admission notes. On May 30, 2025, at 10:06 a.m., during an interview conducted with the CNA, the CNA stated she fed Resident 4 with scrambled eggs and milk for breakfast on March 27, 2025. The CNA stated she was informed Resident 4 was about to get picked up for a scheduled physician appointment that day, so she did not complete the oral care. On June 2, 2025, at 2:45 p.m., during an interview conducted with the DON, the DON stated Resident 4's family member had called her to informed Resident 4 was transferred to the acute care facility, as green beans and egg had been found in her mouth at the physician ' s office during the appointment. The DON stated the resident should have had oral care after each meal to assure no food residue remained. A review of the facility's policy and procedure titled, Activities of Daily Living (ADLs), Supporting, dated March 2018, indicated, .Residents will be provided with care .residents who are unable to carry out the activities of daily living independently will receive the service .to maintain good .oral hygiene .oral care .appropriate care and services will be provided for residents who are unable to carry out ADL ' s independently .including .oral hygiene . 555404 Page 6 of 8 555404 06/02/2025 Riverside Village Healthcare Center 17040 Arnold Dr. Riverside, CA 92518

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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 scheduled hemodialysis (a treatment using a machine and special filter to clean the blood of a kidney failure person) treatments were provided timely, for one of three residents reviewed (Resident 5), when the transportation to the dialysis center was not arranged. Residents Affected - Few This failure resulted in Resident 5 to missed dialysis treatments while at the facility. In addition, this failure had the potential for Resident 5 to increased risk of medical complications including fluid overload (excess fluid in the blood), edema (swelling), shortness of breath, and high blood pressure. Findings: On May 29, 2025, at 8 a.m., an unannounced visit was made to the facility for the investigation of a complaint regarding quality of care and treatment. On May 29, 2025, Resident 5's record was reviewed. Resident 5 was admitted to the facility on [DATE], with diagnoses which included end stage renal disease (a severe condition where the kidneys have permanently lost most of their ability to function). Resident 5 was readmitted back to the facility on May 17, 2025. A review of Resident 5's Minimum Data Set (MDS - a resident assessment tool), dated May 6, 2025, indicated as follows: - Resident 5 had a BIMS (Brief Interview of Mental Status) score of 10 (moderate cognitive impairment), and; - Resident was on hemodialysis. A review of Resident 5's Order Summary, included a physician's order, dated April 2, 2025, which indicated, .Dialysis: Dialysis Center: (Name of Center) .On T-Th-S (Tuesday-Thursday-Saturday) Chair Time:12PM (p.m.) Transportation: (Name of Company) .Pick up at 11:00AM (a.m.) . A review of Resident 5's Nurse ' s Note, dated May 20, 2025, indicated, .pt (patient) missed HD (hemodialysis) today d/t (due to) transportation not arriving . On May 29, 2025, at 1 p.m, an interview was conducted with the Social Service Director (SSD). The SSD stated the transportation for the dialysis schedule should be pre-arranged prior to admission to the facility. The SSD stated if there would be an issue with transportation to the dialysis clinic on the scheduled dialysis, the licensed nurse should call the transport company, notify the dialysis center, physician, and the resident or resident representative. The SSD stated the facility should have followed up with the transport company about Resident 5's dialysis schedule and pick up when the resident was readmitted back to the facility. On May 29, 2025, at 1:45 p.m., during a concurrent interview and record review with Licensed Vocational Nurse (LVN) 2. LVN 2 stated Resident 5 did not receive her dialysis treatment on May 20, 2025, due to transportation did not show up. LVN 2 stated the transportation should have been followed up 555404 Page 7 of 8 555404 06/02/2025 Riverside Village Healthcare Center 17040 Arnold Dr. Riverside, CA 92518

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and arranged prior to dialysis to avoid missed dialysis treatments. LVN 2 further stated, if a resident would not receive dialysis, Resident 5 could have complications such as shortness of breath and edema that could lead to hospitalization. On June 2, 2025, at 2:45 p.m., during an interview with the Director of Nursing (DON), the DON stated she expected for all licensed nurses to follow the facility's policy and procedure of dialysis care. The DON stated the transportation should have been followed up or arranged prior dialysis treatment and should have been communicated to avoid miss treatment. The DON further stated if the resident would not receive a dialysis treatment, resident would increase the risks for medical condition such as fluid overload, respiratory problems and high blood pressure. A review of the facility ' s policy and procedure titled, End-Stage Renal Disease, Care of a Resident with, dated September 2010, indicated, .Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care . A review of the facility ' s transfer agreement titled, NURSING HOME DIALYSIS TRANSFER AGREEMENT, dated, April 2024, indicated, .Facility shall have the responsibility for arranging suitable transportation of the Designated Resident to and from Center, including the selection of the mode of transportation, qualified personnel to accompany the Designated Resident and transportation equipment usually associated with this type of transfer including the use of appropriate life support measures in accordance with the applicable federal and state laws and regulations . 555404 Page 8 of 8