Health inspection·May 23, 2024

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 to provide respiratory care and treatment in accordance with the facilities policy and procedures for two of five residents (Resident 1 and Resident 4) reviewed for oxygen treatment. Residents Affected - Few This failure had the potential to result in ineffective oxygen therapy, respiratory distress, and decline in the residents ' health condition. Findings: On May 22, 2024, at 7:40 am, an unannounced abbreviated survey was conducted for the investigation of one complaint. A review of Resident 1 ' s History and Physical, dated May 25, 2022, indicated Resident 1 was admitted with a medical history which included chronic obstructive pulmonary disease (COPD, a lung disease causing restricted airflow or breathing problems), anxiety disorder (a disorder caused by excessive anxiety), and paranoid schizophrenia (a serious mental disorder that affects how people interpret reality). A review of Resident 1 ' s Physician ' s Orders, dated January 7, 2024, indicated May use Continuous oxygen @ (at) 2-3 L/min (liters per minute) via nasal cannula or face mask for oxygen saturation below 92%. Every shift related to chronic obstructive pulmonary disease with (acute) exacerbation if oxygen is delivered at 3L/min or above, humidifier must be applied. A review of Resident 1 ' s Vital Signs, for oxygen saturation trends indicated, for the dates of January 10, 2024, January 11, 2024, January 12, 2024, and January 13, 2024, was only documented one time per day, instead of every shift as ordered. During a concurrent observation and interview on May 23, 2024, at 7:55 am, with Resident 4, Resident 4 stated he has lived in the facility for one year and uses oxygen on and off throughout the day and while he sleeps every night because of COPD. The oxygen was set at 3.5 liters per minute with humidifier (a device for increasing the humidity of the air) attached. A review of Resident 4 ' s History and Physical, dated December 20, 2023, indicated Resident 4 was admitted with medical diagnoses which include COPD exacerbation (an increase in the severity of the disease), status asthmaticus (a prolonged and severe asthma attack that does not respond to standard treatment), depression, anxiety, and periodic psychosis (loss of contact with reality). A review of Resident 4 ' s Physician Orders, dated March 21, 2024, indicated May use oxygen @ 2-3 Page 1 of 3 555884 555884 05/23/2024 Riverside Heights Healthcare Center, LLC 8951 Granite Hill Drive Riverside, CA 92509

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few L/min via nasal cannula or face mask for oxygen saturation below 88%. Monitor use q shift. As needed if oxygen is delivered at 3 L/min or above, humidifier must be applied. A review of Resident 4 ' s Vital Signs, for oxygen saturation trends, dated March 28, 2024, April 14, 2024, May 1, 2024, May 7, 2024, May 12, 2024, and May 16, 2024, were the only days oxygen saturations were documented. During an interview on May 23, 2024, at 11:00 am, with Administrator, Administrator stated the staff should be documenting oxygen levels per physician orders. A review of the facility ' s policy and procedure titled, Oxygen Therapy, revised November 2017, indicated, .Document administration in the medication administration record .Document oxygen saturation levels per physician order . Based on observation, interview, and record review, the facility failed to provide respiratory care and treatment in accordance with the facilities policy and procedures for two of five residents (Resident 1 and Resident 4) reviewed for oxygen treatment. This failure had the potential to result in ineffective oxygen therapy, respiratory distress, and decline in the residents' health condition. Findings: On May 22, 2024, at 7:40 am, an unannounced abbreviated survey was conducted for the investigation of one complaint. A review of Resident 1's History and Physical, dated May 25, 2022, indicated Resident 1 was admitted with a medical history which included chronic obstructive pulmonary disease (COPD, a lung disease causing restricted airflow or breathing problems), anxiety disorder (a disorder caused by excessive anxiety), and paranoid schizophrenia (a serious mental disorder that affects how people interpret reality). A review of Resident 1's Physician's Orders, dated January 7, 2024, indicated May use Continuous oxygen @ (at) 2-3 L/min (liters per minute) via nasal cannula or face mask for oxygen saturation below 92%. Every shift related to chronic obstructive pulmonary disease with (acute) exacerbation if oxygen is delivered at 3L/min or above, humidifier must be applied. A review of Resident 1's Vital Signs, for oxygen saturation trends indicated, for the dates of January 10, 2024, January 11, 2024, January 12, 2024, and January 13, 2024, was only documented one time per day, instead of every shift as ordered. During a concurrent observation and interview on May 23, 2024, at 7:55 am, with Resident 4, Resident 4 stated he has lived in the facility for one year and uses oxygen on and off throughout the day and while he sleeps every night because of COPD. The oxygen was set at 3.5 liters per minute with humidifier (a device for increasing the humidity of the air) attached. A review of Resident 4's History and Physical, dated December 20, 2023, indicated Resident 4 was admitted with medical diagnoses which include COPD exacerbation (an increase in the severity of the disease), status asthmaticus (a prolonged and severe asthma attack that does not respond to standard 555884 Page 2 of 3 555884 05/23/2024 Riverside Heights Healthcare Center, LLC 8951 Granite Hill Drive Riverside, CA 92509

F 0695 treatment), depression, anxiety, and periodic psychosis (loss of contact with reality). Level of Harm - Minimal harm or potential for actual harm A review of Resident 4's Physician Orders, dated March 21, 2024, indicated May use oxygen @ 2-3 L/min via nasal cannula or face mask for oxygen saturation below 88%. Monitor use q shift. As needed if oxygen is delivered at 3 L/min or above, humidifier must be applied. Residents Affected - Few A review of Resident 4's Vital Signs, for oxygen saturation trends, dated March 28, 2024, April 14, 2024, May 1, 2024, May 7, 2024, May 12, 2024, and May 16, 2024, were the only days oxygen saturations were documented. During an interview on May 23, 2024, at 11:00 am, with Administrator, Administrator stated the staff should be documenting oxygen levels per physician orders. A review of the facility's policy and procedure titled, Oxygen Therapy , revised November 2017, indicated, .Document administration in the medication administration record .Document oxygen saturation levels per physician order . 555884 Page 3 of 3