Health inspection·April 4, 2024

F 0686 Level of Harm - Minimal harm or potential for actual harm In an interview on 04/04/2024 at 4:23 PM, the Director of Nursing stated normally beds with a low air loss mattress did not have sheets on them and she was not sure what happened. A review of a document titled, In-Service Sign in Sheet, dated 08/01/2023, revealed Air loss mattress use draw sheet and chux ONLY. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555884 If continuation sheet Page 2 of 4 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 04/04/2024 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 interviews, record review, document reviews, and facility policy reviews, the facility failed to conduct outbreak testing as directed by the Centers for Disease Control and Prevention when 1 (Resident #119) of 15 sampled residents tested positive for COVID-19. Residents Affected - Few Findings included: A review of the facility policy titled, Infection Prevention and Control Program, revised in June 2021, revealed It is the policy of the facility to establish and maintain and Infection Prevention and Control Program to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections. A review of the undated facility policy titled, Resident COVID Testing, revealed It is the policy of this facility to provide testing for the Covid-19 virus to our residents as directed by the Centers for Disease Control and the California Department of Public Health. A review of the undated facility policy titled, Employee Covid Testing, revealed It is the policy of this facility to provide testing for the Covid-19 virus to our employees as directed by the Centers for Disease Control and the California Department of Public Health. A review of the Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 03/18/2024, revealed a section titled Responding to a newly identified SARS-CoV-2 [severe acute respiratory syndrome coronavirus 2] infected HCP [healthcare personnel] or resident that specified, Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. A review of Resident #119's significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/10/2023, revealed the facility readmitted the resident on 11/03/2023. The MDS revealed the resident had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. Per the MDS, the resident had active diagnoses to include coronary artery disease, hypertension, peripheral vascular disease, renal insufficiency, dementia, and osteoporosis. A review of a document titled, COVID-19 Log, revealed Resident #119 had no symptoms. Per the COVID-19 Log, the date of the test for Resident #119 was listed on 01/09/2024. During an interview on 04/03/2024 at 11:52 AM, the Infection Preventionist (IP) stated the facility's last COVID-19 outbreak occurred on 01/09/2024. According to the IP, a resident (Resident #119) was sent to the hospital on [DATE], and the hospital staff notified the facility that the resident tested positive for COVID-19. The IP acknowledged all residents and staff were then tested weekly, on 01/09/2024 and again on 01/16/2024. A review of documents titled Testing Record, revealed facility staff and residents were tested for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555884 If continuation sheet Page 3 of 4 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 04/04/2024 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 COVID-19 on 01/09/2024, 01/16/2024, and 01/23/2024. Level of Harm - Minimal harm or potential for actual harm During an interview on 04/04/2024 at 10:58 AM, the Director of Nursing stated when the facility had a resident who was positive for COVID-19, the facility tested other residents and staff on the same day as to when the resident was found to be positive for COVID-19 and then weekly thereafter. Residents Affected - Few In an interview on 04/04/24 at 1:37 PM, the Administrator stated she expected the staff to follow the regulations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555884 If continuation sheet Page 4 of 4