Inspection·May 20, 2021

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On May 19, 2021, at 9:05 a.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 reviewed Resident 4's record and stated there was no documentation regarding the resident's skin injuries from shaving. On May 19, 2021, at 10:34 a.m., a concurrent interview and record review was conducted with the Director of Nurses (DON). The DON stated the skin injuries for Resident 4 should have been identified and reported. Resident 4's record was reviewed. Resident 4 was admitted to the facility on [DATE], with diagnoses which included Parkinson's disease (a disorder of the brain that results in uncontrollable shaking). The Minimum Data Set (MDS - an assessment tool), dated April 28, 2021, indicated Resident 4 required one person assistance for his personal hygiene including shaving. A review of the facility policy and procedure titled, CHANGE IN RESIDENT CONDITION, dated November 2017, indicated, .changes in physical .during the care or observation of a resident .All symptoms and unusual signs will be communicated to the physician .promptly . A review of the facility policy and procedure titled, Skin Tears - Abrasions and Minor Breaks, Care of, dated on September 2013, indicated, .Complete in-house investigation of causation . 2. On May 18, 2021, at 10:21 a.m., Resident 470 was observed lying in bed awake and nonverbal. A large dark bluish discoloration on the left neck approximately four by three centimeters and a yellow-greenish fading bruise on the right side of Resident 470's jaw were observed. On May 18, 2021, at 10:26 a.m., Certified Nursing Assistant (CNA) 2 was interviewed. CNA 2 was asked about Resident 470's discoloration on the left neck and right jaw area. CNA 2 stated he noticed Resident 470 had the bruise since last Saturday (May 15, 2021). He stated, I think the charge nurse was aware, regarding Resident 470's bruise. On May 18, 2021, at 10:39 a.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN) 2. LVN 2 reviewed Resident 470's record from April 2021 to May 2021. LVN 2 stated there was no incident report or change in condition documentation for Resident 470 regarding the bruise on the left neck and right jaw. LVN 2 stated she did not receive reports regarding Resident 470's bruising on the left neck and right jaw. On May 18, 2021, at 10:51 a.m., the Director of Nursing (DON) was interviewed. The DON stated the facility's process when a resident had a bruise or change of condition was as follows: The nurse would report to the charge nurse, assess the resident, and then initiate an incident report. The DON stated the charge nurse would notify the physician, responsible party and also the DON or the Administrator after an incident report had been created. The DON stated there should have been an incident report completed for Resident 470's bruises. On May 18, 2020, Resident 470's record was reviewed. Resident 470 was admitted to the facility on [DATE], with diagnosis which included atrial fibrillation (fast and irregular heart beat), Schizoaffective disorder (a mental illness), dementia (memory loss), muscle wasting and atrophy (thinning or loss of muscle tissue). The Minimum Data Set (MDS, an assessment tool), dated March 16, 2021, indicated Resident 470 had a BIMS (Brief Interview for Mental Status - an assessment for cognitive status) of never understood (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555884 If continuation sheet Page 2 of 14 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 555884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Heights Healthcare Center, LLC 8951 Granite Hill Drive 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 (severely impaired). Level of Harm - Minimal harm or potential for actual harm The physician order dated March 10, 2021, indicated, Apixaban Tablet (blood thinner medication) 2.5 MG (milligram - unit of measurement) Give 1 tablet via PEG-Tube (percutaneous endoscopic gastrostomy - tube directly inserted through the skin into the stomach for nutrition, hydration, and medication administration purposes) two times a day. Residents Affected - Few The Care Plan dated May 11, 2020, indicated, .at risk for bleeding, bruising, skin tears, and discoloration related to daily use of Apixaban .Interventions .Assess/document/report PRN (as needed) adverse reactions of Apixaban therapy: .bruising . The facility policy and procedure titled, CHANGE IN RESIDENT CONDITION, dated November 2017, was reviewed. The policy indicated, It is the policy of this facility that changes in resident condition will be communicated to the physician, resident, and/or resident representative, appropriate nursing measures and physician orders implemented and documentation requirements completed FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555884 If continuation sheet Page 3 of 14 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 555884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Heights Healthcare Center, LLC 8951 Granite Hill Drive 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed for one of one resident reviewed for oxygen therapy (Resident 50), to ensure the oxygen nasal cannula tubing (a two-pronged tubing connected to the nose) was labeled indicating the date the nasal cannula tubing was changed. Residents Affected - Few This failure had the potential to result in the nasal cannula tubing to not be changed timely, which could allow infectious organisms to grow causing an infection to Resident 50. Findings: On May 18, 2021, at 11:32 a.m., Resident 50 was observed inside her room, lying in bed, asleep, with a nasal cannula in place, receiving oxygen at 2 LPM (liters per minute- a unit of measurement). The nasal cannula tubing did not have a label indicating the date when the nasal cannula tubing was changed. On May 18, 2021, at 11:35 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated Resident 50's oxygen nasal cannula tubing did not have a label indicating the date when the nasal cannula tubing was changed. LVN 1 stated the licensed nurse on Sunday should have changed the nasal cannula tubing and should have labeled and dated it. On May 18, 2021, at 11:59 a.m., the Registered Nurse Supervisor (RNS) was interviewed. The RNS stated oxygen nasal cannula tubings were changed by the licensed nurses every Sunday and should have a label indicating the date when it was changed. On April 19, 2021, Resident 50's record was reviewed. Resident 50 was admitted under hospice care (care for the sick or terminally ill), on August 29, 2018, with diagnoses that included right breast cancer (abnormal cell growth in the breast). The History and Physical, dated February 8, 2021, indicated Resident 50 did not have the capacity to understand and make decisions. The Order Summary Report dated April 14, 2021, was reviewed. The document indicated .Change and date nasal cannula or face mask and tubing once a week or prn (as needed) when oxygen in use, every night shift every Sun (Sunday) . Resident 50's care plan titled, Chronic Respiratory failure and COPD (chronic obstructive pulmonary disease- a chronic inflammatory lung disease), dated April 14, 2021, indicated, .Change and date nasal cannula or face mask and tubing once a week or prn when oxygen in use . On April 19, 2021, at 9:59 a.m., the Assistant Director of Nursing (ADON) was interviewed. The ADON stated Resident 50's oxygen nasal cannula tubing should have been dated when it was changed. The facility policy and procedure titled, OXYGEN THERAPY, dated November 2017, was reviewed. The policy indicated, .The cannula should be dated with date set-up and/or changed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555884 If continuation sheet Page 4 of 14 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 555884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Heights Healthcare Center, LLC 8951 Granite Hill Drive 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure expired medications were removed from storage and not readily available for use, when: 1. One unopened bottle of milk of magnesia (MOM - medication to treat constipation) expired on April 2021, and one unopened bottle of an iron supplement syrup (medication to treat low iron) expired on February 2021; and 2. One open bottle of multivitamins expired on February 2021, and the multivitamins from the expired bottle were administered to Residents 1, 9, 475, 476, and 477. These failures increased the possibility for the residents to receive expired medications with decreased efficacy, and for Residents 1, 9, 475, 476, and 477 to receive medications unsafely. Findings: 1. During the medication storage inspection conducted with Licensed Vocational Nurse (LVN) 1 on May 19, 2021, beginning at 11:46 a.m., at the Station 1 medication cabinet, the following medications were found readily available for use: - One unopened bottle of MOM with an expiration date of April 2021; and - One unopened bottle of iron supplement syrup with an expiration date of February 2021. On May 19, 2021, at 12:08 p.m., LVN 1 was interviewed. LVN 1 stated there should be no expired medications readily available for use in the medication cabinet at Station 1. 2. During the medication storage inspection conducted with Licensed Vocational Nurse (LVN) 3 on May 19, 2021, beginning at 1:43 p.m., one open bottle of multivitamins with an expiration date of February 2021, was found in the Station 2 medication cart, readily available for use. On May 19, 2021, at 1:58 p.m., LVN 3 was interviewed. LVN 3 stated there should be no expired medications readily available for use in the medication cart. LVN 3 was asked how many residents had a physician's order for multivitamins. LVN 3 stated Residents 1, 9, 475, 476, and 477, had orders for multivitamins and received the expired medication since February 2021. A review of the residents records indicated the following physician orders: - For Resident 1, Multivitamins give one tablet by mouth one time a day for supplement, order date January 27, 2021; - For Resident 9, Multivitamins give one tablet by mouth one time a day for supplement, order date January 28, 2021; - For Resident 475, Multivitamins give one tablet by mouth one time a day for supplement, order date April 24, 2020; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555884 If continuation sheet Page 5 of 14 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 555884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Heights Healthcare Center, LLC 8951 Granite Hill Drive 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 0761 Level of Harm - Minimal harm or potential for actual harm - For Resident 476, Multivitamins give one tablet by mouth one time a day for supplement, order date January 28, 2021; and - For Resident 477, Multivitamins give one tablet by mouth one time a day for supplement, order date February 27, 2021. Residents Affected - Some On May 19, 2021, at 1:58 p.m., the Director of Nursing (DON) was interviewed. The DON stated there should be no expired medications readily available for use in the medication cabinet or the medication cart. The DON stated the licensed nurses should check medication expiration dates before administering any medication. The undated facility policy and procedure titled, STORAGE OF MEDICATIONS, was reviewed. The policy indicated, .Outdated .are immediately removed from inventory, disposed of according to procedures for medication disposal .The nurse will check the expiration date of each medication before administering it .No expired medication will be administered to a resident .All expired medications will be removed from the active supply . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555884 If continuation sheet Page 6 of 14 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 555884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Heights Healthcare Center, LLC 8951 Granite Hill Drive 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on interview and record review, the facility failed to ensure two food service personnel were able to safely and effectively carry out the functions of the food and nutrition services when one [NAME] and one Dietary Aide (DA) were unable to demonstrate and verbalize the process of manual dishwashing by using a two-compartment sink. This failure had the potential to place 51 out of 58 highly susceptible residents who received food from the kitchen at risk for food-borne illness. Findings: During an interview on May 17, 2021, at 9:30 a.m., the DA verbalized and demonstrated the process of manual dishwashing with the two-compartment sink. The DA stated usually they used the two-compartment sink for wash and rinse pots and pans only and then would use the dishwashing machine for sanitizing process. The DA stated she was not sure the wash and rinse water temperature for manual dishwashing. She also stated she could not completely demonstrate and verbalized the whole process of manual dishwashing. During an interview on May 17, 2021, at 9:32 a.m., the [NAME] verbalized the process of manual dishwashing with the two-compartment sink. The [NAME] stated the process was washing and rinsing would use the same sink and she would clean and sanitize the sink between washing and rinsing. She stated the water temperature for the wash and rinse would be at least 110 degrees Fahrenheit (F). She stated the sanitizing solution was premixed and load in the sanitizing sink and the sanitizer solution concentration should be 200 parts per million (ppm) by using the quaternary ammonia (quat) test strip. The [NAME] stated she then put the dishes, pots, or pans into the quat solution fully immerse for 10 seconds, and last step was to air dried. During an interview on May 17, 2021, at 9:38 a.m., the Dietary Services Supervisor (DSS) acknowledged the DA did not know the process of manual dishwashing and the [NAME] verbalized the incorrect immersion time of pots, pans, and dishes in the quat solution, and the correct immersion time was at least 60 seconds. She stated her expectation for the dietary aide staff and the Cooks should have the knowledge of manual dishwashing in case the dishwashing machine was not functioning. During an interview on May 19, 2021, at 2:50 p.m., the Registered Dietitian (RD) stated her expectation for the Cooks and dietary aide staff should know the process of manual dishwashing. The RD stated they should know the dishes, pans, and pots needed to be fully immerse into the sanitizing solution for at least one minute (60 seconds) for the sanitation procedure for the manual dishwashing. A review of competency audits of the DA and the [NAME] and a concurrent interview were conducted on May 19, 2021, at 1:48 p.m. The facility documents titled, Food and Nutrition Services Competency Check List, completed on November 10, 2020 for the Cook, and completed on March 11, 2021 for the DA, and both showed that the DA and the [NAME] were competent to demonstrate two- or three-compartment sink dishwashing method and evaluated by the DSS. The DSS stated all dietary aide staff were cross-trained and worked as dishwashers when scheduled. She stated they should know the process of manual and machine dishwashing. The DSS also stated the [NAME] must have the knowledge of everything in the kitchen from food safety, sanitation, and dishwashing because she would be responsible for the kitchen when the DSS was not available. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555884 If continuation sheet Page 7 of 14 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 555884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Heights Healthcare Center, LLC 8951 Granite Hill Drive 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 0802 Level of Harm - Minimal harm or potential for actual harm A review of facility policy and procedure titled, Cleaning Dishes - Manual Dishwashing, dated 2008, it indicated wash and rinse water temperature should be a minimum of 110 degrees F, and sanitize dishes by immersion in quaternary ammonium solution for 60 seconds. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555884 If continuation sheet Page 8 of 14 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 555884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Heights Healthcare Center, LLC 8951 Granite Hill Drive 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 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to ensure that the menu was being following for the therapeutic diet for lunch on May 18, 2021 when: Residents Affected - Some 1. Two residents (Resident 76 and 564) on regular puree (regular diet modifies in texture of a smooth and moist consistency and able to hold its shape. Foods usually in soft and smooth state such as pudding or mashed potatoes) diet did not receive sauce on the puree chicken as indicated on the menu; 2. Two residents (Resident 475 and 469) on regular CCHO (consistent carbohydrate) diet (a diet used in the treatment for diabetes) did not receive diet gelatin dessert as indicated on the menu; and 3. One resident (Resident 53) on CCHO Large portion received extra one and half ounces of regular barbeque (BBQ) chicken. These failures had the potential to result in compromising the medical and nutrition status of those five residents. Findings: 1. During an observation of lunch meal service on May 18, 2021, beginning at 12:00 p.m., it was noted Resident 76 and 564 were on regular puree diet did not receive sauce on the puree chicken. A concurrent review of the undated facility document titled, Spring Cycle Menus: Week 3 Tuesday, showed that puree diet should receive puree BBQ chicken with sauce. During an interview on May 18, 2021, at 1:16 p.m., the Dietary Services Supervisor (DSS) acknowledged both residents with puree diet which not fortified did not receive sauce for the puree chicken. The DSS stated that the puree BBQ chicken should be with sauce per menu and it helped moisturizing the meat and swallowing. 2. During an observation of lunch service on May 18, 2021, beginning at 12:00 p.m., it was noted Resident 475 and 469 were on regular CCHO diet on the meal tickets (a ticket including resident's diet, date, allergies, specific food and beverage items, dislikes, and likes) received regular strawberry gelatin whip as dessert. A concurrent review of undated facility document titled, Spring Cycle Menus: Week 3 Tuesday, indicated regular CCHO diet should receive diet strawberry gelatin whip. During an interview on May 18, 2021, at 1:16 p.m., the DSS stated she was aware that the dietary aide did not provide the diet strawberry gelatin whip dessert to Resident 475 and 469. 3. During an observation of lunch service on May 18, 2021, beginning at 12:00 p.m., it was noted Resident 53 was on CCHO large portion on the meal ticket received one and a half piece (four and a half ounces) of regular BBQ chicken. A concurrent review of undated facility document titled, Spring Cycle Menus: Week 3 Tuesday, indicated CCHO large portion should receive three ounces of BBQ chicken with lite BBQ sauce. During an interview on May 18, 2021, at 1:16 p.m., the DSS acknowledged Resident 53 on CCHO large portion diet received extra portion (one and half ounces) of chicken and the chicken should be with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555884 If continuation sheet Page 9 of 14 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 555884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Heights Healthcare Center, LLC 8951 Granite Hill Drive 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 0803 lite BBQ sauce for CCHO. Level of Harm - Minimal harm or potential for actual harm During an interview on May 18, 2021, at 1:25 p.m., the DSS stated her expectation was the Cooks and dietary aide staff should follow the menu to provide adequate nutrition and the right modified and therapeutic diets to the residents. Residents Affected - Some During an interview on May 19, 2021, at 2:50 p.m., the Registered Dietitian (RD) stated the Cooks and the dietary staff should follow the menu during the meal service. The RD stated the puree diet should have received sauce as indicated to moisturize and give better taste of the puree chicken. She stated residents with CCHO diet should have received diet strawberry gelatin whip for dessert to prevent increasing the glucose (blood sugar) level. She also stated the resident with CCHO large portion diet should have received the portion of the chicken as indicated on the menu which it was calculated to help with glucose control and the lite BBQ sauce was less in sugar. A review of facility policy and procedure titled, Standardized Recipes, dated 2008, indicated that Cooks are expected to use and follow the recipes provided. A review of undated facility document titled, Job Description: Cook, showed .the [NAME] should prepare and serve food as directed by the menu .prepare food for meals, including modified foods for restricted and therapeutic diets, in proper quantity and serve in proper portion sizes . A review of undated facility document titled, Job Description: Dietary Aide, showed .prepare hot and cold foods .following recipes and posted menus, for regular, modified and therapeutic diets .serve food for meal delivery by reading tray card .check carefully .correct type of food and texture as ordered by the diet . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555884 If continuation sheet Page 10 of 14 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 555884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Heights Healthcare Center, LLC 8951 Granite Hill Drive 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when: Residents Affected - Many 1. Several various size of metal sheet pans were stacked and stored wet; and 2. The ice machine was not cleaned and sanitized properly per manufacturer's guidance. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food in the facility. The facility census was 58. Findings: 1. During the initial tour in the kitchen, an observation and concurrent interview with the Dietary Services Supervisor (DSS) on May 17, 2021, at 9:10 a.m. was conducted. Two of two-third (2/3) size metal pans, two of one-quarter (1/4) size metal pans, four of full sheet metal pans were observed stacked wet and stored in the clean storage area. The DSS confirmed the mental pans were wet and stacked on top of each other. She stated that all dishes, pots, and pans should be air-dried and completely dried before stored away in the storage area. During an interview on May 19, 2021, at 2:50 p.m., the Registered Dietitian (RD) stated all dishes, pots, pans, and utensils needed to be air-dried before stored away. She stated the moisture environment could induce bacteria or mold growth. During a review of facility policy and procedure titled, Cleaning Dishes - Dishwashing, dated 2008, it indicated after washed, rinsed and sanitized, all dishes should be air-dried, and staff should check all dishes to be sure they are clean and dry prior to storing. During a review of facility document titled, Dietary In-Service Record, Topic: Kitchen Sanitation, completed on January 9, 2020 and February 4, 2021, it showed .To provide safe food, dietary still will follow sanitation guidelines which include .Dishes should be air dried .Inspect for .dryness before putting away . According to FDA Federal Food Code 2017, Section 4-901.11 Equipment and Utensils, Air-Drying Required, after cleaning and sanitizing, equipment, and utensils .shall be air-dried .before contact with food. 2. During an observation on May 17, 2021, at 10:24 a.m., the ice machine had several visible dark brown and black residues on the ice baffle (a panel uses to direct the flow of the ice stored in the ice storage bin) when the Maintenance Supervisor (MS) took it apart from the ice machine. The residues were easily removed with a white paper towel. In addition, there was significant amount of yellow and orange slimy residue around the ice chute (area where the ice is dispensed) and was easily removed with a white paper towel. A concurrent interview with the MS, he confirmed the residues on the ice baffle and ice chute. The MS stated he was responsible for the deep cleaning of the ice machine monthly and the last deep clean was on April 20, 2021. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555884 If continuation sheet Page 11 of 14 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 555884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Heights Healthcare Center, LLC 8951 Granite Hill Drive 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many The MS explained the steps of the cleaning of the ice machine. He stated he would empty the ice from the ice storage bin, took off the parts apart, and washed and rinsed the tubing and water reservoir at the top machinery part of the ice machine. Then he would use manufacturer's brand cleaning solution add in the water reservoir per manufacturer's instruction. The MS also stated the next step was to run the cycle with adding the manufacturer's brand sanitizer solution without mixing any water per manufacturer's instruction to the water reservoir. After those cycles were done, he would run two cycles with clean water and drain. The MS explained the step of cleaning and sanitizing the ice storage bin. He stated he would clean and scrub the interior the ice storage bin with the same manufacturer's cleaning solution and then rinse with water. Then he would use the same sanitize solution mix with water in a bucket to sanitize the ice storage bin. He stated he would rinse with water again after sanitizing the ice storage bin. During a review of the manufacturer's brand cleaning solution bottle on May 17, 2021, at 11:40 a.m., the instruction indicated to use of three to six ounces (oz.) of cleaning solution per gallon of circulating water of the ice machine. A concurrent interview with the MS, he stated he did not know the amount of circulating water for the ice-machine. During a review of the manufacturer's brand sanitizing solution bottle on May 17, 2021, at 11:40 a.m., the instruction for the sanitizing solution indicated to use of eight ounces of the sanitizing solution per five gallons of water for food contact sanitizing performance. The other instruction for sanitizing the ice machine indicated that to allow all surface to air dried after sanitizing and do not rinse after sanitized. A concurrent interview with the MS, he stated he was not sure the amount of sanitizing solution put in the circulating water and did not know the amount of gallon of the circulating water for the ice-machine. The MS also acknowledged that he should not rinse with water after sanitizing the ice storage bin after he read the manufacturer's instruction on the sanitizer solution bottle. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555884 If continuation sheet Page 12 of 14 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 555884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Heights Healthcare Center, LLC 8951 Granite Hill Drive 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 0880 Provide and implement an infection prevention and control program. 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 implement infection control precautions to prevent cross-contamination (transfer of bacteria or other contaminants from one surface to another) when: Residents Affected - Few 1. One facility staff was observed wearing artificial fingernails while assisting in feeding Resident 31 ; and 2. One facility staff did not perform hand hygiene and did not disinfect the blood pressure cuff in between uses for Residents 29 and 39. These failures had the potential to increase the risk of cross-contamination which could result in the development and transmission of infection to a vulnerable population of 58 residents in the facility. Findings: 1. On April 17, 2021, at 12:25 p.m., during dining observation in the main dining room, Certified Nursing Assistant (CNA) 3 was observed wearing artificial fingernails while assisting in feeding Resident 31. On April 17, 2021, at 12:28 p.m., the Director of Staff Development (DSD) was interviewed. The DSD stated CNA 3 was wearing artificial fingernails. The DSD stated artificial fingernails were not allowed in the facility. On April 17, 2021, at 12:30 p.m., CNA 3 was interviewed. CNA 3 stated she was wearing artificial fingernails. CNA 3 stated she was aware artificial fingernails were not allowed in the facility. On April 17, 2021, at 12:35 p.m., the Director of Nursing (DON) was interviewed. The DON stated artificial fingernails were not allowed in the facility. The DON stated the DSD and the Infection Preventionist (IP) should have monitored the staff wearing artificial fingernails. On April 20, 2021, Resident 31's record was reviewed. Resident 31 was admitted on [DATE], with diagnoses that included dementia (memory loss) and schizoaffective disorder (a mental disorder). The History and Physical, dated September 16, 2020, indicated Resident 31 did not have the capacity to understand and make decisions. Resident 31's Minimum Data Set (MDS- an assessment tool) dated April 24, 2021, was reviewed. Resident 31's functional status required one person assistance with eating. According to the Centers for Disease Control and Prevention (CDC - a leading national public health institute in the United States) website, .Germs can live under artificial fingernails both before and after using an alcohol-based hand sanitizer and hand washing. It is recommended that healthcare providers do not wear artificial fingernails or extensions when having direct contact with patients . The facility policy and procedure titled, DRESS CODE AND APPEARANCE, dated January 2019, was reviewed. The policy indicated, .(Name of facility) does not allow it's employees to have artificial fingernails . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555884 If continuation sheet Page 13 of 14 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 555884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Heights Healthcare Center, LLC 8951 Granite Hill Drive 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. On May 17, 2021, at 12:05 p.m., during an observation of the dining room, while residents were playing bingo, Certified Nursing Assistant (CNA) 4 was observed taking Resident 39's blood pressure. CNA 4 was observed using a blood pressure wrist cuff (machine use to measure the resident's blood pressure via the wrist) on the resident, then CNA 4 proceeded to obtain Resident 29's blood pressure. CNA 4 did not perform hand hygiene and did not disinfect the blood pressure cuff, before, in between, and after using the blood pressure cuff on Residents 39 and 29. On May 20, 2021, at 1:53 p.m., a telephone interview was conducted with CNA 4. CNA 4 stated he did not follow the facility's policy regarding the disinfection of blood pressure wrist cuffs when taking residents blood pressures. CNA 4 stated he should have followed the facility policy. On May 20, 2021, at 2:10 p.m., the Director of Staff Development (DSD) was interviewed. The DSD stated CNA 4 should have disinfected the blood pressure cuff before and after use and between Residents 39 and 29. On May 20, 2021, at 2:30 p.m., the Infection Preventionist (IP) was interviewed. The IP stated the facility policy was to use disinfecting wipes before and after use of the blood pressure cuff. The IP stated CNA 4 should have performed hand hygiene before and after each contact with the residents. The facility policy and procedure titled, POLICY FOR CLEANING & DISINFECTING BLOOD PRESSURE MACHINE AND BLOOD PRESSURE CUFF, dated November 2017, was reviewed. The policy indicated, .The blood pressure cuff and gauge will be cleaned after each use with a disinfectant wipe . The facility policy and procedure titled, HAND HYGIENE PROGRAM, dated November 2017, was reviewed. The policy indicated, .Indications for performing hand hygiene .Before and after contact with resident or the their (sic) environment .After touching items that are likely to be contaminated . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555884 If continuation sheet Page 14 of 14