Riverside Postacute Care

F-F584).

On March 21, 2025, at 11:30 a.m., an interview and a concurrent record review was conducted with the Administrator (ADM) to discuss the facility's QAPI program. The ADM stated the QAPI committee consisted of the ADM, the Director of Nursing, the Medical Director, the Infection Preventionist, the Pharmacy consultant, the Laboratory representative, and the heads of the facility departments. The ADM stated the facility did not have a QAPI program which identified, corrected, and improved the issues related to CNA staffing, dietary services, and laundry services for their residents.

A review of facility's policy and procedure titled, Quality Assurance & Performance Improvement (QAPI) Committee, dated July 2022, indicated, .The committee develops, implements and monitors appropriate plans of action to address quality issues identified internally or by regulatory agencies .The committee collects and maintains all audits, reports, and worksheets containing confidential date and clinical issues .

The QAPI Committee responsibilities include identifying and responding to quality deficiencies throughout

the facility and oversight of the QAPI program when fully implemented, develop and implement corrective action and monitor performance goals or target are achieved and revising corrective action .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of 70 555330 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555330 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverside Postacute Care 8781 Lakeview Avenue 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40988 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure infection prevention and Residents Affected - Some control practices were upheld when:

1. During lunch meal observation on March 17, 2025, Resident 36's IV (intravenous- into the vein) tubing was observed touching the food on her plate;

2. Two laundry staff stated they did not routinely check the washer and dryer temperatures. In addition, they were not able to state what the temperature requirements were for washing and drying linen and clothes; and

3. One laundry staff was observed placing linen that was touched by a resident, back into an uncovered linen cart. In addition, the laundry staff covered the clean linen in a large linen bin, with a linen cover that came in contact with the floor.

These failures had the potential to spread infection among the vulnerable residents of the facility.

Findings:

1. On March 17, 2025, at 12:08 p.m., an observation of the lunch meal service at the dining room was conducted. Resident 36 was observed seated at a dining table. An IV access was on top of Resident 36's left hand, with the tubing loose, without an end cap, and was touching the food on her plate.

On March 20, 2025,a t 9:08 a.m., Registered Nurse 1 was interviewed. RN 1 confirmed she was the licensed nurse who taped Resident 36's IV tubing onto her left hand. RN 1 stated if the IV tubing was exposed like that and was touching the food, there was a high risk for infection to occur. RN 1 further stated the IV tubing should have been taped securely in place to prevent the tubing from touching the food and getting contaminated.

On March 21, 2025, at 1:56 p.m., the Infection Preventionist (IP) was interviewed. The IP stated Resident 36's IV tubing should have been taped to her hand, and maybe a netting put in place, to secure it to the hand and prevent it from touching the food on her plate, otherwise she could get an infection.

A review of the facility's policy and procedure titled, PREVENTING INTRAVENOUS CATHETER-RELATED INFECTIONS, dated April 1, 2011, indicated, .The purpose of this procedure is to maximally reduce the risk of infection associated with indwelling intravenous (IV) catheters .Any time that dressing is not intact or end caps are missing, the catheter has potential of contamination .

2. On March 19, 2025, at 2:02 p.m., an observation of the laundry room was conducted in the presence of

the Housekeeping and Laundry Supervisor (HLS) and Laundry Staff (LS) 1. Clothes dryers #2, #3 and #4 were on and in use, as well as clothes washers #2 and #3.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of 70 555330 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555330 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverside Postacute Care 8781 Lakeview Avenue 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 In a concurrent interview, LS 1 stated she did not conduct any temperature checks for the clothes washers and dryers, but the Maintenance Director (MD) did. LS 1 stated the water temperature was automatically set Level of Harm - Minimal harm or for the clothes washers and they did not check them, because we might burn ourselves. LS 1 stated she potential for actual harm knew what the wash settings were, but not the required water temperature for laundering linens and clothes. LS 1 explained the different heat settings for the dryers, stating the low setting was used for pillows, the Residents Affected - Some medium setting was used for linens, and the hot setting was used for blankets. LS 1 was unable to state what the temeperatures were for each setting, as well as the minimum temperature requirement for drying linens and clothes.

In a concurrent interview, the HLS was unable to state the minimum temperature requirements for both the clothes washers and dryers, and was unable to state what the temperatures were for the different clothes dryer settings. The HLS further stated she did not conduct temperature checks of the clothes washers and dryers since I do not have the thermometer to check it.

On March 19, 2025, at 3:54 p.m., The MD was interviewed. The MD stated the laundry equipment did not have external temperature gauges on them, so he checked the equipment temperatures using an infrared gun. The MD further stated he did not keep a log to keep track of the equipments' temperatures to show the required temeperature standards were met.

On March 21, 2025, at 10:37 a.m., the Infection Preventionist (IP) was interviewed. The IP stated the laundry staff should have been aware of the required equipment temperatures for washing and drying, to ensure potential infectious microorganisms were not spread in the facility. The IP further stated the DM should have had a way to track and ensure that proper laundry equipment temperatures were met.

A review of the Washers-Extractors operation manual, dated December 2023, indicated the hot water specifciation was 185 degrees Fahrenheit (a thermal unit of measurement).

A review of the Tumble Dryers, operation manual, dated July 2017, indicated dryer setting temperature settings were as follows: low= 120 degrees Fahrenheit, medium= 170 degrees Fahrenheit, and hot= 190 degrees Fahrenheit.

A review of CFR 42 SS 483.2 (e) Guidelines indicated, .Recommendations for laundry processed in hot water temperatures is 160 (degrees) F (71 C [centigrade- a thermal unit of measurement] ) for 25 minutes.

3. On March 20, 2025, at 10:26 a.m., the HS was observed removing clean linen from the emergency linen closet in Station 2, near room [ROOM NUMBER], and placing them inside an uncovered linen cart . A resident in a wheelchair was observed approaching the linen cart and picked up a clean bed liner, stating he needed it. The HLS was then observed to remove the bed liner from the resident's hands and returned the bed liner to the linen cart containing the clean linens. The HLS proceeded to restock the rest of the linen closets from the uncovered linen cart.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of 70 555330 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555330 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverside Postacute Care 8781 Lakeview Avenue 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 The HLS was followed as she went to the laundry room with the uncovered linen cart that still contained some linens. Upon reaching the laundry room, the HLS stated she was going to fold clean blankets and Level of Harm - Minimal harm or restock the linen closets with them. The HLS placed the folded clean blankets into a large grey portable bin potential for actual harm designated for clean laundry. The HLS then transferred the remaining linen from the uncovered linen cart that she brought back to the laundry room. The HLS proceeded to pick up the brown linen cover that was Residents Affected - Some partially on the floor, and covered the grey linen bin with it.

In a concurrent interview, the HLS stated she should not have put back the item that the resident grabbed, back into the clean linen cart. The HLS further stated she should not have put the linen cover that was touching the floor to cover the clean linen bin.

On March 21, 2025, at 10:37 a.m., the IP was interviewed. The IP stated she expected the HLS to remove

the particular linen that the resident had touched, and put it in the dirty linen bin before proceeding to restock

the other linen closets. The IP stated she also expected the HLS to get a clean linen cover to use on the clean linen bin. The IP further stated whatever was on the floor could transfer to the residents if the contaminated linens were distributed.

A review of the facility's policy and procedure titled, Distributing Clean and New Linen, dated November 2017, indicated, .Load clean linen onto the clean linen cart .Cover the entire cart .Transport the covered cart to the storage area .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 68 of 70 555330 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555330 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverside Postacute Care 8781 Lakeview Avenue 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 0908 Keep all essential equipment working safely.

Level of Harm - Minimal harm or 44504 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure equipment in the kitchen was Residents Affected - Few maintained in a safe operating condition when condensation ice buildup was found on the fans in the reach

in freezer.

This failure had the potential to place 153 out of 153 residents who received food from the kitchen at risk for not receiving quality of foods.

Findings:

On March 17, 2025, at 10:11 a.m., an observation of the reach in freezer at kitchen was conducted. Condensation ice buildup was observed on the two fans in the reach in freezer. Puddle of ice buildup was observed on the surface of a box of cut corn located at the second shelf.

On March 17, 2025, at 10:43 a.m., an interview was conducted the Food and Nutrition Services Director (FNS) and [NAME] (CK)1 in front of the reach in freezer at the kitchen. The FNS acknowledged the reach in freezer was not working properly with condensation ice buildup. CK 1 stated condensation ice buildup at the reach in freezer randomly happened in the past two (2) weeks.

On March 18, 2025, at 11:27 a.m., an interview was conducted with the Engineering Plant Director (EPD).

The EPD stated the reach in freezer defrost time had messed up with the daylight saving time change. The EPD further stated temperature fluctuations lead to condensation and eventually ice formation which could affect the quality of foods stored in the freezer. The EPD stated he did not receive any verbal or written work ordered from the dietary department regarding malfunction of the reach in freezer.

A review of facility policy and procedure tilted, Sanitation, dated 2023, indicated, .all .equipment shall be . maintained in good repair .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 69 of 70 555330 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555330 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverside Postacute Care 8781 Lakeview Avenue 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Level of Harm - Minimal harm or 44504 potential for actual harm Based on observation, interview, and record review, the facility failed to maintain an effective pest control Residents Affected - Some program to ensure the facility remained free of pests when four bugs, one (1) spider, and one (1) house fly were found in the kitchen.

This failure had the potential to place 153 out of 153 residents who received food from the kitchen at risk for food borne illnesses (illness caused by food contaminated with bacteria, viruses, parasites or toxins).

Findings:

On March 17, 2025, at 10:30 a.m., a concurrent observation and interview with the Food and Nutrition Services Director (FNS) was conducted at the dry storage room inside the kitchen. Four bugs (brown color with wings) and one spider were observed on the ceiling. The FNS stated the kitchen should not have any pests as it could cause cross contamination (bacteria are unintentionally transferred from one substance or object to another with harmful effect) of the foods stored in dry storage and lead to food borne illnesses.

On March 18, 2025, at 5:30 p.m., an observation was conducted in front of steamtable inside the kitchen. A house fly was observed to land on the window.

On March 20, 2025, at 9:33 a.m., a phone interview was conducted with the Registered Dietician (RD). The RD stated the kitchen supposed to be pests free to prevent cross contamination and infection control issue.

A review of the facility's policy and procedure titled, Pests Control, dated April 2018, indicated, .POLICY: It is

the policy of the facility to maintain an ongoing pest control program to ensure the building premises and its grounds are kept free of insects, rodents, and other pests. PURPOSE: To ensure that facility is free of insects, rodents and other pest that could compromise the health, safety and comfort of residents, staff and visitors .

A review of the facility's policy and procedure titled, MISCELLANEOUS AREAS, dated 2023, indicated, .FLY AND VERMIN CONTROL Flies are carries of disease and are a constant enemy of high standards of sanitation in the Food & Nutrition Services Department .

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F-F812):

1. The food service workers did not follow the manufacturer's guideline regarding the length of time for testing the red bucket Quaternary (Quat) sanitizer (sanitizing solution used for sanitizing food contact surfaces);

2. The food service workers did not know the appropriate concentration of the Quat sanitizer;

3. Diet Aides (DA) 1 and 3 were unable to demonstrate the proper steps to clean the dirty meal carts;

4. [NAME] (CK) 2 and Diet Aide 2 did not know how to calibrate the food thermometer; and

5. Diet Aides 3 and 4 did not know how long they need to submerge washed kitchen ware in the sanitizer sink.

These failures had the potential to cause foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites or toxins) for 153 out of 153 sampled residents who received foods from the kitchen.

Findings:

1. On March 17, 2025, a review of the test strip manufacturer's guidelines indicated the test strip need to be dipped into the Quat sanitizer for 10 seconds.

On March 17, 2025, at 3:59 p.m., an observation was conducted with DA 3. DA 3 was asked to demonstrate to check the concentration of the Quat sanitizer in the sanitizer bucket. DA 3 dipped the test strip into the sanitizer for 1 second, the test strip was unable to read the sanitizer concentration without showing any change in the color. DA 3 was observed the second time and DA 3 used another sanitizer bucket and dipped

the test strip into the Quat sanitizer bucket for 3 seconds.

On March 17, 2025, at 4:07 p.m., a concurrent observation and interview was conducted with CK 2. CK 2 was asked to demonstrate to check the concentration of Quat sanitizer in the sanitizer bucket. CK 2 stated

he needed to dip the test strip into sanitizer for 15 seconds.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 70 555330 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555330 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverside Postacute Care 8781 Lakeview Avenue 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 On March 20, 2025, at 9:33 a.m., an interview was conducted with the Registered Dietitian (RD). The RD stated the test strip needed to be dipped into the Quat sanitizer for 10 seconds. The RD explained if food Level of Harm - Minimal harm or services workers did not follow manufacturer guideline's time length in dipping the test strip into Quat potential for actual harm sanitizer, it could result in an inaccurate reading of the sanitizer concentration which could not ensure the effectiveness of the sanitizer. The RD explained using ineffective Quat sanitizer could result to not properly Residents Affected - Some sanitize food contact surfaces which could cause cross contamination and lead to food borne illness.

A review of the facility's policy and procedure titled, QUATERNARY AMMONIA LOG POLICY, dated 2023, indicated, .POLICY .The concentration of the ammonium in the quaternary (Quat) sanitizer will be tested to ensure the effectiveness of the solution . Read instructions on quaternary container and the test strips for proper concentration, length of time the strip needs to be in contact with the solution .when testing for concentration

2. On March 17, 2025, a review of the manufacturer's guidelines for Quat sanitizer posted above the three compartment sink indicated, .Testing solution should be between 200 -400 parts per million (ppm - a unit of measurement) .

On March 17, 2025, at 11:53 a.m., an interview was conducted with DA 2. DA 2 was asked to test the Quat sanitizer in the sanitizer bucket. DA 2 stated Quat sanitizer needed to be between 200 -300 ppm. DA 2 stated 400 ppm was not right concentration because the concentration was too strong.

On March 17, 2025, at 3:37 p.m., an interview was conducted with DA 4. DA 4 was asked to test the Quat sanitizer in the sanitizer bucket. DA 4 stated Quat sanitizer range needed to be between 200 -300 ppm. DA 4 stated 400 ppm was not right because the sanitizer was too concentrated.

On March 17, 2025, at 3:59 p.m., an interview was conducted with DA 3. DA 3 was asked to demonstrate to check the concentration of Quat sanitizer in the sanitizer bucket. DA 3 stated Quat sanitizer should be only in 200 ppm.

On March 17, 2025, at 4:07 p.m., a concurrent observation and interview was conducted with CK 2. CK 2 was asked to demonstrate to check the concentration of Quat sanitizer in the sanitizer bucket. CK 2 stated Quat sanitizer should be only in 200 ppm. CK 2 stated 200 - 400 was not right concentration.

On March 20, 2025, at 9:33 a.m., a phone interview was conducted with the RD. The RD stated Quat Sanitizer should be between 200 - 400 ppm. and all food service workers should know the concentration range.

A review of the facility's policy and procedure titled, QUATERNARY AMMONIA LOG POLICY, dated 2023, indicated, .POLICY .The concentration of the ammonium in the quaternary (Quat) sanitizer will be tested to ensure the effectiveness of the solution . Read instructions on quaternary container and the test strips for proper concentration, length of time the strip needs to be in contact with the solution .when testing for concentration

3. On March 17, 2025, at 9:59 AM, an interview was conducted with DA 1. DA 1 was asked to demonstrate how to clean used meal cart. DA 1 stated she used green bucket (soap and water) to clean the meal cart and then sanitize with sanitizer.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 70 555330 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555330 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverside Postacute Care 8781 Lakeview Avenue 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 On March 17, 2025, at 3:59 PM, an interview was conducted with DA 3. DA 3 was asked to demonstrate how to clean used meal cart. DA 3 stated he only used sanitizer to clean the used meal cart. Level of Harm - Minimal harm or potential for actual harm On March 20, 2025, at 9:33 AM, an interview was conducted with the RD. The RD stated not using cleaning procedure with wash, rinse and sanitizer could result not properly sanitize the used meal cart which cause Residents Affected - Some cross contamination and lead to food borne illness.

A review of the facility Policy and procedure (P&P) titled, SANITATION, dated 2023, the P&P indicated, . PROCEDURE: .4. Each employee shall know how to .clean all equipment .

A review of the facility's policy and procedure titled, SHELVES, COUNTERS, AND OTHER SURFACES INCLUDING .FOOD PREPARATION ., dated 2023, indicated, CLEANING PROCEDURE: 1. Remove any large debris and wash surface with a warm detergent solution .Rinse with clear water .Spray with a sanitizer .

4. On March 17, 2025, at 4:07 p.m., a concurrent observation and interview was conducted with CK 2. CK 2 was asked to demonstrate how to calibrate the thermometer used to check the temperature of the food to be served. CK 2 got a cup of ice filled with water and then put the thermometer inside. CK 2 stated he needed to calibrate the thermometer to 40 degrees Fahrenheit ( F - a unit of measurement).

On March 18, 2025, at 11:11 a.m., a concurrent observation and interview was conducted with DA 2. DA 2 was asked to demonstrate how to calibrate the thermometer. DA 2 got a cup of ice filled with water and then put the thermometer inside. DA 2 stated she needed to calibrate the thermometer to 39 F.

On March 20, 2025, at 9:33 a.m., an interview was conducted with the RD and the FSN. The RD stated the thermometer needed to be calibrated to 32 F. The FSN stated the potential risk for thermometers which were not properly calibrated by the dietary staff when they check the food temperature could cause foodborne illnesses.

A review of the facility's policy and procedure titled, THERMOMETER USE AND CALIBRATION, dated 2023,

the indicated, .Food thermometers are to be used properly and calibrated to ensure accurate temperature reading .If the thermometer does not read 32 F, then the thermometer must be calibrated or discarded .

A review of the professional reference retrieved from the Centers for Disease Control and Prevention (CDC) document titled, Food Safety, dated October 15, 2021, indicated, .Food is safely cooked when the internal temperature gets high enough to kill germs that can make you sick. The only way to tell if food is safely cooked is to use a food thermometer. You can't tell if food is safely cooked by checking its color and texture . Use a food thermometer to ensure foods are cooked to a safe internal temperature .

5. On March 17, 2025, a review of the manufacturer's guidelines for three compartment sink cleaning procedures posted above three compartment sink indicated, .Place items in Sanitizing Solution for 1 minute .

On March 17, 2025, at 3:37 p.m., an interview was conducted with DA 4. DA 4 was asked how long he need to submerge the washed kitchen ware in the sanitizer in the sanitizing sink. DA 4 was unable to answer the question.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 70 555330 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555330 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverside Postacute Care 8781 Lakeview Avenue 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 On March 17, 2025, at 3:59 p.m., an interview was conducted with DA 3. DA 3 was asked how long he need to submerge the washed kitchen ware in the sanitizer in the sanitizing sink. DA 3 stated washed kitchen ware Level of Harm - Minimal harm or need to be submerged into the sanitizer for 10 seconds. potential for actual harm

On March 20, 2025, at 9:33 a.m., an interview was conducted with the RD and the FSN. Both of the RD and Residents Affected - Some the FSN stated they were unsure how long washed kitchen ware needed to be submerged into the sanitizer

in the sanitizing sink.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 70 555330 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555330 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverside Postacute Care 8781 Lakeview Avenue 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 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. Level of Harm - Minimal harm or potential for actual harm 44504

Residents Affected - Some Based on observations, interviews and record reviews, the facility failed to ensure food were prepared according to the prescribed recipe, when:

1. [NAME] 1 did not add margarine to a fortified diet during the noon meal on March 17, 2025;

2. Food service workers did not have a system to distinguish a diet Jello for Controlled Carbohydrate Diet

during the noon meal on March 17, 2025;

3. [NAME] 2 did not use the right scoop to portion salad for dinner on March 18, 2025;

4. [NAME] 2 did not use the right scoop to portion meat for dinner on March 18, 2025; and

5. Diet Aide 5 did not measure the amount of shredded cheese to be placed in cheese quesadilla on March 18, 2025.

These failures had the potential to negatively impact the residents' nutritional status and further compromising the resident's medical status.

Findings:

1. On March 17, 2025, a review of the facility's document titled Fortified Menu Plan (diet with added extra nutrients to increase the calories and/or protein density to promote improvement residents' nutrition status) posted next to the trayline (a system of food preparation in which trays move along an assembly line), indicated, .lunch .vegetable per menu. Extra 1/2 oz melted margarine

On March 17, 2025, starting at 12:40 p.m. to 1:08 p.m., a concurrent observation and meal tray ticket (menu based on the resident's diet physician order and food preference) review was conducted with Resident 5, 86, 14, 83, 102, 22, and 72, at the dining room, during lunch meal observation. Resident 5, 86, 14, 83, 102, 22, and 72's meal ticket indicated, Fortified. Resident 5, 86, 14, 83, 102, 22, and 72's served lunch meal was observed without margarine served on the vegetable.

On March 17, 2025, at 1:08 p.m., a concurrent observation, interview and meal tray ticket review was conducted with Resident 72 and Certified Nurse Aide (CNA) 2 at dining room. Resident 72 meal ticket indicated, Fortified. Resident 72's served lunch meal was observed, there was no margarine on served vegetable. CNA 2 confirmed there was no margarine on any food items served as entree including the vegetable.

On March 18, 2025, at 10:27 a.m., an interview was conducted with [NAME] (CK) 1. CK 1 stated during lunch, fortified diet residents should receive margarine on the served vegetable.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 70 555330 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555330 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverside Postacute Care 8781 Lakeview Avenue 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 On March 18, 2025, at 10:46 a.m., an interview was conducted with the Registered Dietitian (RD). The RD stated fortified diet residents should serve margarine on their vegetable during lunch. The RD explained Level of Harm - Minimal harm or fortified diet residents who had an order for fortified diet did not get the extra calories per diet menu plan potential for actual harm which could affect their nutritional status since there was no margarine on the vegetable.

Residents Affected - Some A review of Resident 5, 86, 14, 83, 102, 22, and 72's physician diet order, indicated the residents had an order for fortified diet.

A review of the facility's policy and procedure titled, FORTIFIED DIET, dated 2020, indicated, DESCRIPTION: The Fortified Diet is designed for residents who cannot consume adequate amounts calories and/or protein to maintain their weight or nutritional status. NUTRITIONAL BREAKDOWN: The goal is to increase the calories density of the foods commonly consumed by the resident. The amount of calories increase should be approximately 300 - 400 per day. FOODS: Examples of adding calories may include - Extra margarine or butter to food items such as vegetables .

A review of the facility's policy and procedure titled, MENU PLANNING, dated 2023, indicated, .The menu are planned to meet nutritional needs of residents in accordance with .Physician's orders .PROCEDURES . Standardized recipes .used in food preparation .

A review of the facility's policy and procedure titled, FACILITY REGISTERED DIETITAN APPROVAL OF MENUS, dated 2023, indicated, .The facility Registered Dietitian has reviewed the menus and spreadsheets and has agreed that the menus meet the therapeutic needs .

2. A review of the facility provided Cooks Spreadsheet (the document used to guide food service workers on food items, portions, and therapeutic diet), dated March 17, 2025, indicated, Controlled Carbohydrate Diet (CCHO) served Diet Gelatin (Jello).

On March 17, 2025, at 11:30 a.m., an observation was conducted with Dietary Aide (DA) 7 at the kitchen. DA 7 was observed putting Jello on meal tray.

On March 17, 2025, starting at 12:41 p.m. to 1:11 p.m., a concurrent observation and meal tray ticket review was conducted with Residents 86, 80, 83, 133, 127, 72, and 101, during lunch meal observation at the dining room. Resident 86, 80, 83, 133, 127, 72, and 101's meal ticket indicated, CCHO. Residents 86, 80, 83, 133, 127, 72, and 101, were observed to receive red colored Jello which looked the same as the regular Jello and there was no label to indicate the Jello was diet.

On March 18, 2025, at 10:22 a.m., an interview was conducted with DA 7. DA 7 stated she could not distinguish which Jello was diet and which Jello was regular without a label on the Jello.

On March 18, 2025, at 10:46 a.m., an interview was conducted with the RD. The RD stated the Jello needed to be labeled diet or regular. The RD stated CCHO diet residents should be served diet Jello per menu plan.

The RD stated there could be a potential risk for residents with CCHO diet who consumed regular Jello could increase the resident's blood sugar level.

A review of Resident 86, 80, 83, 133, 127, 72, and 101's physician diet order, indicated Residents 86, 80, 83, 133, 127, 72, and 101's were on CCHO diet.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 70 555330 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555330 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverside Postacute Care 8781 Lakeview Avenue 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 A review of the facility document titled, CONTROLLED CARBOHYDRATE DIET (CCHO), dated 2020, indicated, .CCHO, is a meal plan without specific calories levels for diabetic residents. Instead of counting Level of Harm - Minimal harm or calories; the carbohydrates are evenly, systematically and consistently distributed through three meals and potential for actual harm evening snacks in an effort to maintain a stable blood sugar level throughout the day .The carbohydrates are controlled through portion control and avoiding some concentrated sweets .Provide .Diet gelatin .Diet fruits Residents Affected - Some packed in water or 100% fruit juice, not syrup .

A review of the facility's policy and procedure titled, MENU PLANNING, dated 2023, indicated, .The menu are planned to meet nutritional needs of residents in accordance with .Physician's orders .

A review of the facility's policy and procedure titled, FACILITY REGISTERED DIETITAN APPROVAL OF MENUS, dated 2023, indicated, .The facility Registered Dietitian has reviewed the menus and spreadsheets and has agreed that the menus meet the therapeutic needs .

3. On March 18, 2025, a review of the facility provided Cooks Spreadsheet, dated March 18, 2025, indicated, . Tossed [NAME] Salad: Regular portion .1/2 cup .

On March 18, 2025, at 4:42 p.m., an observation was conducted with the Food and Nutrition Services Director (FNS). The FNS was observed using the blue scoop (1/4 cup) to portion the green salad.

On March 21, 2025, at 9:33 a.m., a concurrent interview and review of the Cooks Spreadsheet dated March 18, 2025 was conducted with the RD and the FSN. The FSN stated [NAME] (CK) 2 started using blue scoop to portion the green salad. The FNS stated she jumped in to help CK 2 as he was running out of time. The FSN did not realize CK 2 used the wrong scoop to portion the green salad. After reviewing the Cooks Spreadsheet, the RD and the FSN acknowledged CK 2 served half portion less than the menu plan. The RD stated Residents did not get the proper nutrition and the right amount serving size they were supposed to get per menu plan which could lead to nutritional deficit and could potentially result in weight loss.

A review of the facility's policy and procedure titled, MENU PLANNING, dated 2023, indicated, .The menus are planned to meet nutritional needs of residents in accordance with established national guidelines, Physician's order and, to the extent medically possible, in accordance with the most recommended dietary allowances of the Food and Nutrition Board of the National Research Council National Academy of Sciences .

A review of the facility's policy and procedure titled, FACILITY REGISTERED DIETITAN APPROVAL OF MENUS, dated 2023, indicated, .The facility Registered Dietitian has reviewed the menus and spreadsheets and has agreed that the menus meet the therapeutic needs .

4. A review of the facility provided Cooks Spreadsheet, dated March 18, 2025, the Cooks Spreadsheet indicated . Beef Teriyaki: Regular portion: number (#) 12 scoop .

On March 18, 2025, at 5:21 p.m., an observation was conducted with CK 2 at trayline. CK 2 was observed using # 8 scoop (4 oz) instead of # 12 scoop (3.25 oz) per menu to portion the beef teriyaki .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 70 555330 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555330 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverside Postacute Care 8781 Lakeview Avenue 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 On March 21, 2025, at 9:33 a.m., a concurrent interview and review of the Cooks Spreadsheet dated March 18, 2025, was conducted with the RD and the FSN. After reviewing the Cooks Spreadsheet, the RD and the Level of Harm - Minimal harm or FSN acknowledged CK 2 served more meat per planned menu to the residents. The RD stated the residents potential for actual harm did not get the proper nutrition and the right amount of protein serving size they were supposed to get per planned menu which could lead to excess nutrients intake and resulted to weight gain. The RD stated CK 2 Residents Affected - Some gave more meat to the residents, and he might run out of meat during trayline.

A review of the facility's policy and procedure titled, MENU PLANNING, dated 2023, indicated, .The menus are planned to meet nutritional needs of residents in accordance with established national guidelines, Physician's order and, to the extent medically possible, in accordance with the most recommended dietary allowances of the Food and Nutrition Board of the National Research Council National Academy of Sciences .

A review of the facility's policy and procedure titled, FACILITY REGISTERED DIETITAN APPROVAL OF MENUS, dated 2023, indicated, .The facility Registered Dietitian has reviewed the menus and spreadsheets and has agreed that the menus meet the therapeutic needs .

5. On March 18, 2025, at 4:48 p.m., a concurrent observation and interview was conducted with DA 5 at the cook area. DA 5 was observed to make cheese quesadilla. DA 5 grabbed two (2) handful of shredded cheese from a plastic container without measuring and then put on the flour tortilla to make cheese quesadilla. DA 5 stated she had no idea how much shredded cheese she used to make the cheese quesadilla. DA 5 was unable to locate the cheese quesadilla recipe.

On March 20, 2025, at 9:33 a.m., an interview was conducted with the RD and the FSN. The FSN stated DA 5 needed to follow the recipe and should use a scoop to measure the shredded cheese to be placed on the flour tortilla to make cheese quesadilla. The RD stated the residents could receive inconsistent nutrients needs if the recipe were not followed .

A review of the facility's policy and procedure titled, MENU PLANNING, dated 2015, indicated, . PROCEDURES .Standardized recipes .used in food preparation .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 70 555330 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555330 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverside Postacute Care 8781 Lakeview Avenue 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or 50705 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure food were served at Residents Affected - Some appropriate temperatures, were palatable (the taste and/or flavor of the food) and with variety of foods, according to the residents' preferences and the facility's policy and procedure, for nine residents (Resident 23, 35, 52, 66, 91, 103,107, 132, and 146) out of 153 residents who receive food from the kitchen.

This failure placed residents at potential risk to decrease nutritional intake and affect the resident's nutritional status.

Findings: (Cross reference 805)

On March 17, 2025, at 10:02 a.m., during an interview with Resident 52, Resident 52 stated, Served food is warm not hot; cold food not cold; like ice cream sometimes is melty.

On March 17, 2025, at 10:20 a.m., during an interview with Resident 66, Resident 66 stated, The food mostly does not have much taste; 80 percent of the time.

On March 17, 2025, at 11:30 a.m., during an interview with Resident 91, Resident 91 stated, Food served same thing day after day. The food is cold.

On March 17, 2025, at 11:59 a.m., during an interview with Resident 146, Resident 146 stated, The food sucks. Somedays food is warm and somedays its cold and bland.

On March 17, 2025, at 12:08 p.m., during an interview with Resident 103, Resident 103 stated, Food is not good. It is cold.

On March 18, 2025, at 9:57 a.m., during an interview with Resident 35, Resident 35 stated, Every breakfast comes cold.

On March 18, 2025, at 2:12 p.m., during an interview with Resident 23, Resident 23 stated, Food is bland and cold when it served.

On March 18, 2025, at 2:25 p.m., during an interview with Resident 107, Resident 107 stated, A lot of times food its cold and bland.

On March 18, 2025, at 3:03 p.m., during an interview with Resident 132, Resident 132 stated, Food is cold.

On March 18, 2025, at 6:29 p.m., during a concurrent interview and test tray (to evaluate the quality of a meal during a meal service and identify any areas for improvement) conducted at dining room with the Food and Nutrition Service Director (FNS), a test tray was conducted to check the food temperature and palatability of the regular and puree diet meals. The following temperatures were obtained from the test tray:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 70 555330 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555330 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverside Postacute Care 8781 Lakeview Avenue 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 0804 - Regular diet for beef teriyaki: 111 degrees Fahrenheit ( F - a unit of measurement); [NAME] bean: 100 F; Rice: 100 F. Level of Harm - Minimal harm or potential for actual harm - Pureed diet: Mashed potatoes: 105 F; Carrot: 104 F.

Residents Affected - Some In a concurrent interview, the FNS acknowledged pureed beef teriyaki was not the right diet texture. The FNS stated pureed beef teriyaki did not have a smooth mashed potato texture with the beef fiber still intact.

The FNS stated the residents could choke on it, the resident could spit out the beef which could lead to decreased intake and cause weight loss. The FNS stated [NAME] (CK) 2 needed to use ground meat or pureed the beef longer to make it smooth like mashed potato texture. The FNS admitted CK 2 prolonged boiling green beans which caused the green beans to have an olive color. The FNS acknowledged the served beef teriyaki meat for regular diet was tough and mashed potatoes taste gross.

On March 20, 2025, at 9:33 a.m., during an interview with the Registered Dietitian (RD), the RD stated serving cold and unpalatable food could lead to the residents' decreased meal intake. The RD explained decreased meal intake could result in residents to not receive the proper nutrition they needed, which could cause weight loss and nutritional deficiency.

A review of the facility's policy and procedure titled, MEAL SERVICE, dated 2023, indicated, .POLICY .Meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner, and served at the appropriate temperatures .Temperature of the food when the resident receives it is based on palatability. The goal is to serve cold food cold and hot food hot .Recommended Temperature at Delivery to Resident .Hot Entree more than or equal to 120 degrees Fahrenheit .Starch: more than or equal to 120 degrees Fahrenheit .Vegetables: more than or equal to 120 degrees Fahrenheit .

A review of the facility's policy and procedure titled, FOOD PREPARATION, dated 2023, indicated, .POLICY: Food shall be prepared by methods that conserve nutritive value, flavor, and appearance. PROCEDURE . Prepared food will be sampled. The Food and Nutrition Services employee who prepares the food will sample it to be sure food has a satisfactory flavor and consistency .Poorly prepared food will not be served-such food is to either be improved, prepared again, or replaced with an appropriate substitution. Note that increased amounts of herbs and spices (not salt) may be added, since potency of products may vary .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 70 555330 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555330 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverside Postacute Care 8781 Lakeview Avenue 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 0805 Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Level of Harm - Minimal harm or potential for actual harm 44504

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure the appropriate food texture was provided when:

1. For 13 of 13 residents who received pureed diet (is a diet with food texture need to blend until smooth for residents who have difficulty chewing and/or swallowing) received pureed meat that were not smooth with meat fiber still intact for dinner on March 18, 2025;

2. For Resident 39 who had a physician order for nectar thick liquid received lumpy milk and a regular shake

during lunch on March 18, 2025;

3. For Resident 85 who had physician ordered for nectar thick liquid received pudding consistency milk and Jello during lunch on March 18, 2025; and

These failures had the potential to place the residents at risk of choking, aspiration (when food is breathed into the lungs), coughing and decreased meal or fluid intake.

Findings:

1. On March 18, 2025, at 4:38 p.m., a concurrent observation and interview was conducted with [NAME] (CK) 2. CK 2 was observed preparing pureed meat. CK 2 stated he was preparing 18 servings of pureed meat for residents on pureed diet.

On March 18, 2025, at 6:29 p.m., a test meal (to evaluate the quality of a meal during a meal service and identify any areas for improvement) was performed for palatability of the puree diet with the Food and Nutrition Services Director (FNS). The pureed beef texture was observed to have beef fiber still intact. The FNS stated pureed foods should be smooth with mashed potato texture. The FNS stated currently served pureed beef texture not smooth with fiber of meat still intact. The FNS stated CK 2 should leave the beef in

the blender to be blended for a longer period to reach the smooth mashed potato texture. The FNS stated residents on pureed diet could choke with this texture and spill out the beef which lead to decrease meal intake and could potentially result in weight loss.

A review of the facility document titled Diet Type Report, dated March 19, 2025, indicated Residents 1, 16, 34, 41, 39, 67, 85, 97, 117, 121, 152, 157 and 318 had physician's order for pureed diet.

A review of the facility document titled, Pureed Diet, indicated, .The pureed diet is a regular diet that has been designed for residents who have difficulty chewing and/or swallowing. The texture of the food should be of a smooth and moist consistency and able to hold its shape

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 70 555330 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555330 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverside Postacute Care 8781 Lakeview Avenue 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 0805 2. On March 17, 2025, at 11:32 a.m., a concurrent observation, interview, and record review of the instructions of making thickened liquid was conducted with Diet Aide (DA) 6. DA 6 was observed preparing Level of Harm - Minimal harm or nectar thick liquid. DA 6 stated he followed the chart instructions making nectar liquid. The chart instructions potential for actual harm of making thickened liquid was reviewed, which indicated, .Measure the recommended amount of [brand (thickener)] to achieve desired consistency .Slowly add [brand (thickener)] to liquid while stirring briskly until Residents Affected - Some dissolved. Liquid will thicken within 1-5 minutes. Recommended Usage: Desired Consistency: Nectar -Like .1 tablespoon per 4 fluid oz serving . DA 6 was observed add thickener and milk according to the instructions and then stirred the liquid. The thickener was observed to be still on the bottom of the cup.

On March 17, 2025, at 1:20 p.m., a concurrent observation, interview, and review of Resident 39's meal ticket was conducted at Resident 39's bedside with Licensed Vocational Nurse (LVN) 6 and Certified Nurse Aide (CNA) 2. Resident 39's meal ticket indicated, Nectar thick liquid, 4 fluid ounces (oz- a unit of measurement) 2 percent (%) milk; 4 fluid oz supplement shake. The 4 fluid oz 2% milk was observed with

the thickener still sit on the bottom of the cup. LVN 6 and CNA 2 acknowledged the served nectar thick milk was not mix well with lumps and still had some thickener on bottom of the cup. LVN 6 acknowledged Resident 39 received regular shake. LVN 6 stated Resident 39 could aspirate if the resident consumed the regular shake.

On March 18, 2025, at 10:46 a.m., an interview was conducted with the RD. The RD stated Resident 39 should receive nectar thick shake instead of regular shake. The RD explained Resident 39 could potentially cough and aspirate with drinking regular health shake. The RD stated the residents who were on nectar thick liquid who received lumpy liquid could discourage them to drink the liquid which could lead to decreased fluid intake.

A review of Resident 39's physician order, dated July 14, 2023, indicated, Diet . nectar thick liquid consistency .

3. On March 17, 2025, at 1:20 p.m., a concurrent observation, interview, and review of Resident 85's meal ticket was conducted with LVN 6. Resident 85's meal ticket indicated, Nectar thick liquid. Resident 85 was observed to receiv Jello and pudding thick consistency milk. LVN 6 stated it would discourage Resident 85 to drink the pudding consistent milk. LVN 6 stated Resident 85 was not suppose to receive Jello because Jello would melt in her mouth and could become regular liquid which could cause coughing and aspiration.

On March 18, 2025, at 10:46 a.m., an interview was conducted with the RD. The RD stated Residents who were on nectar thick liquid could not have Jello because Jello would melt in mouth and could cause coughing and aspiration. The RD stated it would discourage Resident 85 to drink pudding consistency milk which could lead to decrease fluid intake.

A review of Resident 85's physician order, dated February 1, 2025, indicated, .Diet . nectar thick liquid consistency .

A review of the facility's policy and procedure titled, DIET ORDERS, dated 2023, indicated, .POLICY: Diet orders as prescribed by the physician will be provided by the Food and Nutrition Services Department .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 70 555330 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555330 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverside Postacute Care 8781 Lakeview Avenue 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 0805 A review of the facility document titled, NUTRITIONAL MANAGEMENT OF THICKENED LIQUIDS, dated 2020, indicated, DESCRIPTION .Aspiration is, often, the result of Dysphagia (difficulty swallowing) and Level of Harm - Minimal harm or prevention of aspiration is the goal when utilizing thickened liquids. Thickened liquids help to slow the potential for actual harm movement of liquids/drinks, allowing residents to have better control over their swallow. Dysphagia is characterized by coughing or choking after swallowing, pocketing of food in the check, excessive drooling, Residents Affected - Some runny nose or eyes, gargled voice after eating, or poor tongue control .All liquids/drinks should be thickened to meet the prescribed order .Nectar thick liquids-Flows off spoon; pours slower than thin drinks; sippable; thin liquids will require thickening .Avoid foods that become liquids at room temperature e.g .gelatin (Jello) .

A review of the facility's policy and procedure titled, MEAL SERVICE, dated 2023, indicated, .Meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 70 555330 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555330 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverside Postacute Care 8781 Lakeview Avenue 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 0809 Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to Level of Harm - Minimal harm or eat at non-traditional times or outside of scheduled meal times. potential for actual harm 44504 Residents Affected - Many Based on observation, interview, and record review, the facility failed to ensure bedtime snacks were offered and were sufficient, for 153 of 153 residents who received food from the kitchen.

This failure had the potential to affect the nutritional and psychosocial wellbeing of residents.

Findings:

On March 18, 2025, at 9:59 a.m., during the confidential resident council meeting, five out of 10 residents stated bedtime snacks were not offered and sufficient for them.

On March 18, 2025, at 10:06 a.m., an interview was conducted with Resident 120. Resident 120 stated she is diabetic, and the facility did not have sugar free or diabetic evening snacks available for her.

On March 18, 2025, at 7:09 p.m., a concurrent observation and interview was conducted with Dietary Aide (DA) 3 at the kitchen. There were three plastic containers observed in the walk in refrigerator. Each container stored two (2) sandwiches, 12 individual single serving package graham crackers; 10 individual single serving package saltine crackers, six (6) bananas; three (3) oranges, two (2) Jello, two (2) apple sauce and two (2) puddings. DA 3 stated the Activity staff would come to the kitchen daily around 7:00 p.m. and took those snacks to be distributed to the residents.

On March 19, 2025, at 2 p.m., an interview was conducted with the Activity Assistant (AS) 1. AS 1 stated she went to the kitchen around 7 p.m. to get evening snacks and offered them to the residents. AS 1 stated she needed more evening snacks because most of the residents wanted snacks and requested more than one snack. AS 1 stated the residents love fruits, she usually did not have enough fruit offered to the residents. AS 1 stated since there were not enough snacks to distribute, there fore no snacks were left available in the station counter for those residents who missed the time period when she offered the snacks.

On March 19, 2025, at 2:14 p.m., an interview was conducted with AS 2. AS 2 stated current provided evening snacks were not enough to offer to the residents. AS 2 stated she needed more snacks to distribute to the residents.

On March 20, 2025, at 9:33 a.m., a phone interview was conducted with the Registered Dietician (RD). The RD stated, the facility is like a home for the residents if residents were not offered or did not get enough bedtime snacks, the residents did not feel they are at home, they feel hungry and unhappy.

A review of the facility's policy and procedure titled, Nourishment Policy, dated March 2016, indicated, . bedtime snacks of a nourishing quality will be offered routinely to all residents unless contraindicated .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 70 555330 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555330 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverside Postacute Care 8781 Lakeview Avenue 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50705

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and distributed in accordance with professional standards for food service safety when:

1. Dust was observed on several areas (dry storage room and back door frame) in the kitchen;

2. Dietary Aide (DA 4) and Engineering Plant Director (EPD) had facial hair and were not wearing a hair restraint;

3. Two opened food items were exposed to the air in the walk-in freezer;

4. The walk in refrigerator gasket was found to have black grime buildup;

5. Three baking pans of pizza were stored underneath the steam table which was near a sanitizer bucket, and with air gap;

6. Wilting produce (three cucumbers and 2 green bell peppers) were found in the walk in refrigerator;

7. The cabinet used to store kitchen ware had chipped wood;

8. Two hot waterspouts had calcium buildup;

9. Unsanitary ice bags were placed on the floor of the facility lobby;

10. Eight expired boxes of English muffins were found in dry storage pantry;

11. A dirty rag was placed on the clean coffee cart;

12. The food service workers did not follow the manufacturer's guideline regarding the length of time for testing the red bucket Quaternary (Quat) sanitizer (sanitizing solution used for sanitizing food contact surfaces);

13. The food service workers did not know the appropriate concentration of the Quat sanitizer;

14. Diet Aides (DA) 1 and 3 were unable to demonstrate the proper steps to clean the dirty meal carts;

15. [NAME] (CK) 2 and Diet Aide 2 did not know how to calibrate the food thermometer; and

16. Diet Aides 3 and 4 did not know how long they need to submerge washed kitchen ware in the sanitizer sink.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 70 555330 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555330 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverside Postacute Care 8781 Lakeview Avenue 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 The facility's failures to ensure a safe and sanitary condition had the potential to result for microorganisms (a microscopic organism, especially a bacterium, virus, or fungus) that harbor foodborne pathogens (a Level of Harm - Minimal harm or bacterium, virus, or other microorganism that can cause disease) to come in contact with residents' food potential for actual harm which would cause food-borne illness to a population of 153 of 153 residents who received food from the kitchen and are medically compromised. Residents Affected - Some Findings:

1. On [DATE REDACTED], at 9:29 a.m., a concurrent observation and interview was conducted with the Food and Nutrition Services Director (FNS) in the kitchen. Dust was observed on the doorway frames of the dry storage pantry . The FNS stated dust were found on the dry storage pantry's doorway frames.

On [DATE REDACTED], at 9:58 a.m., a concurrent observation and interview were conducted with the FNS at the back door entrance to the kitchen. Dust was observed on the doorway frames. The FNS verified dust on the doorway frames at the entrance back door.

On [DATE REDACTED], at 9:33 a.m., a telephone interview with the Registered Dietitian (RD) and FNS was conducted.

The RD stated dust should not be in the kitchen because it could cause cross contamination.

During a review of the U.S. Federal and Drug Administration (FDA) Food Code 2022, ,d+[DATE REDACTED].13 Nonfood-Contact Surfaces , the Food code indicated, The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests.

2. On [DATE REDACTED], at 12:07 p.m., an observation was conducted with Dietary Aide (DA) 4 in the kitchen. DA 4's facial hair was observed to be not restrained while DA 4 was working in the tray line.

On [DATE REDACTED], at 4:16 p.m., an observation and interview with the FNS was conducted in the kitchen. The EPD was observed to have facial hair and was not restrained while working in the walk-in refrigerator. The FNS stated the EPD should wear a beard net. The FNS stated the staff with facial hair, including DA 4 should wear a beard net to prevent cross contamination.

On [DATE REDACTED], at 9:33 a.m., a telephone interview with the RD was conducted. The RD stated facial hair should be covered when in the kitchen because it could fall in the food and cause cross contamination.

A review of the policy and procedure titled, Dress Code, dated 2023, indicated, .Proper Dress: If applicable, beards and mustaches (any facial hair) must wear beard restraint .

3. On [DATE REDACTED], at 10:14 a.m., a concurrent observation, and interview was conducted with the FNS at the reach-in freezer. One open bag of frozen carrots, and another open bag of frozen green beans were found exposed to air in the reach-in freezer. The FNS stated frozen food items should be sealed to prevent freezer-burn, and other food items from falling into the exposed frozen vegetables to prevent unappetizing taste and potential cross contamination.

On [DATE REDACTED], at 9:33 a.m., a telephone interview with the RD was conducted. The RD stated the opened food items should be sealed in order to preserve freshness and taste.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 70 555330 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555330 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverside Postacute Care 8781 Lakeview Avenue 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 During a review of the policy and procedure titled, Procedure For Freezer Storage, dated 2023, indicated, . Procedure: Store frozen foods in an airtight moisture-resistant wrapper such as a plastic bag or freezer paper Level of Harm - Minimal harm or to prevent freezer burn . potential for actual harm 4. On [DATE REDACTED], at 11:21 a.m., a concurrent observation and interview was conducted with the FSN in the Residents Affected - Some walk-in refrigerator. Black grime build up was observed on the refrigerator door's gasket. The FNS stated the refrigerator gasket needs to be replaced to prevent cross contamination.

On [DATE REDACTED], at 9:33 a.m., a telephone interview with the RD was conducted. The RD stated the walk-in refrigerator door's gasket not supposed to have black grime buildup which could cause cross contamination.

During a review of the policy and procedure titled, SANITATION, dated 2023, indicated, .All .equipment shall be kept clean .

5. On [DATE REDACTED], at 3:29 p.m., a concurrent observation and interview was conducted with the FNS at the trayline. Three pans of pizza were observed at the bottom of the trayline shelf, next to the cleaning and sanitizer buckets, and with an air gap. The FNS stated We don't do that, because it can cause cross contamination.

On [DATE REDACTED], at 9:33 a.m., a telephone interview with the RD and the FNS was conducted. The RD stated the pizza should have been placed on a higher surface, to prevent cross contamination.

During a review of the policy and procedure titled, Sanitation, dated 2023, indicated, .Do not use cleaning products or sanitizer in the food preparation or food storage areas in any way that could result in contamination of exposed food items.

6. On [DATE REDACTED], at 11:21 a.m., a concurrent observation and interview was conducted with the FNS in the walk-in refrigerator. Three wilted cucumbers and two wilted bell peppers were observed on the refrigerator shelf. The FNS stated the refrigerator gasket needs to be replaced to prevent cross contamination. The FNS further stated the wilted vegetables need to be thrown away, so the residents could not get sick from being served spoiled vegetables.

On [DATE REDACTED], at 9:33 a.m., a telephone interview with the RD and the FNS was conducted. The RD stated wilted vegetables should not be in the refrigerator because it can affect the freshness of other produce in the refrigerator. The RD further explained stated wilted vegetables could lead to bacteria growth and cross contamination of other produce stored in refrigerator.

During a review of the facility's policy and procedure titled, Procedure for Refrigerated Storage, dated 2023, indicated, .Produce will be be .free of any wilting or spoilage .

7. On [DATE REDACTED], at 11:48 a.m., an observation was conducted with the FNS in the kitchen. Chipped wood werer observed on the shelves used to store kitchenware. The FNS stated the cabinets should not be chipped because it can cause cross contamination.

On [DATE REDACTED], at 9:33 a.m., a telephone interview with the RD and the FNS was conducted. The RD stated the cabinet wood should not be chipped, because it could cause cross contamination.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 70 555330 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555330 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverside Postacute Care 8781 Lakeview Avenue 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 During a review of the facility's policy and procedure titled, Sanitation, dated 2023, indicated, .All .counters shall be .free from .chipped areas . Level of Harm - Minimal harm or potential for actual harm 8. On [DATE REDACTED], at 11:49 a.m., an observation was conducted with the FNS in the kitchen. Calcium buildup was observed on two hot waterspouts. Residents Affected - Some

On [DATE REDACTED], at 9:33 a.m., a telephone interview with the RD and the FNS was conducted. The RD stated the calcium buildup should be removed, because it could get in the food and water and could cause cross contamination.

During a review of the policy and procedure titled, Sanitation, dated 2023, indicated, .All utensils, couters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions .cracks, and chipped areas .

9. On [DATE REDACTED], at 8:34 a.m., an observation was conducted in the lobby. Bags of ice were observed on the floor and at the front desk.

On [DATE REDACTED], at 11:27 a.m., an interview was conducted with the EPD. The EPD confirmed the facility had to get the ice this morning because last night someone accidentally turned off the ice machine.

On [DATE REDACTED], at 9:33 a.m., a telephone interview with the RD and the FNS was conducted. The RD stated ice should not be on the floor or the desk, because it was not sanitary and could cause contamination of the ice.

During a review of the policy and procedure titled, Sanitation, dated 2023, indicated, .Ice which is used in connection with food or drink shall be from a sanitary source and shall be handled and dispensed in a sanitary manner .

10. On [DATE REDACTED], at 11:50 a.m., an observation was conducted in the kitchen. A dirty rag was observed on the clean coffee cart.

On [DATE REDACTED], at 9:33 a.m., a telephone interview with the RD and the FNS was conducted. The RD stated dirty rags should not be placed in the kitchen. The RD stated the dirty rags needed to be in a basket for soiled laundry. The RD stated dirty rags in the kitchen could cause cross contamination.

During a review of the U.S. Federal and Drug Administration (FDA) Food Code 2022, ,d+[DATE REDACTED].14 Wiping Cloths, Use Limitation. , the Food code indicated, .Cloths in-use for wiping counters and other EQUIPMENT surfaces shall be: (1) Held between uses in a chemical sanitizer solution at a concentration

11. On [DATE REDACTED], at 9:40 a.m., a concurrent observation and interview were conducted with the FNS in the kitchen. Eight boxes of English muffins, with an expiration date of [DATE REDACTED], were found in the dry storage pantry. The FNS stated expired food items should not be stored as the food could be served to residents and potentially cause illness.

On [DATE REDACTED], at 9:33 a.m., a telephone interview with the RD and the FNS was conducted. The RD stated expired food should not be in the kitchen because it could harm someone.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 70 555330 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555330 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverside Postacute Care 8781 Lakeview Avenue 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 During a review of the U.S. Federal and Drug Administration (FDA) Food Code 2022, indicated, .Annex 3: Manufacturer's use-by dates .Manufacturers assign a date to products for various reasons, and spoilage may Level of Harm - Minimal harm or or may not occur before pathogen growth renders the product unsafe. Most, but not all, sell-by or use-by potential for actual harm dates are voluntarily placed on food packages . Although it is a guide for quality, it could be based on food safety reasons. It is recommended that food establishments consider the manufacturer's information as good Residents Affected - Some guidance to follow to maintain the quality (taste, smell, and appearance) and salability of the product. If the product becomes inferior quality-wise due to time in storage, it is possible that safety concerns are not far behind .

12. On [DATE REDACTED], a review of the test strip manufacturer's guidelines indicated the test strip need to be dipped into the Quat sanitizer for 10 seconds.

On [DATE REDACTED], at 3:59 p.m., an observation was conducted with DA 3. DA 3 was asked to demonstrate to check

the concentration of the Quat sanitizer in the sanitizer bucket. DA 3 dipped the test strip into the sanitizer for 1 second, the test strip was unable to read the sanitizer concentration without showing any change in the color. DA 3 was observed the second time and DA 3 used another sanitizer bucket and dipped the test strip into the Quat sanitizer bucket for 3 seconds.

On [DATE REDACTED], at 4:07 p.m., a concurrent observation and interview was conducted with CK 2. CK 2 was asked to demonstrate to check the concentration of Quat sanitizer in the sanitizer bucket. CK 2 stated he needed to dip the test strip into sanitizer for 15 seconds.

On [DATE REDACTED], at 9:33 a.m., an interview was conducted with the Registered Dietitian (RD). The RD stated the test strip needed to be dipped into the Quat sanitizer for 10 seconds. The RD explained if food services workers did not follow manufacturer guideline's time length in dipping the test strip into Quat sanitizer, it could result in an inaccurate reading of the sanitizer concentration which could not ensure the effectiveness of the sanitizer. The RD explained using ineffective Quat sanitizer could result to not properly sanitize food contact surfaces which could cause cross contamination and lead to food borne illness.

A review of the facility's policy and procedure titled, QUATERNARY AMMONIA LOG POLICY, dated 2023, indicated, .POLICY .The concentration of the ammonium in the quaternary (Quat) sanitizer will be tested to ensure the effectiveness of the solution . Read instructions on quaternary container and the test strips for proper concentration, length of time the strip needs to be in contact with the solution .when testing for concentration

13. On [DATE REDACTED], a review of the manufacturer's guidelines for Quat sanitizer posted above the three compartment sink indicated, .Testing solution should be between 200 -400 parts per million (ppm - a unit of measurement) .

On [DATE REDACTED], at 11:53 a.m., an interview was conducted with DA 2. DA 2 was asked to test the Quat sanitizer

in the sanitizer bucket. DA 2 stated Quat sanitizer needed to be between 200 -300 ppm. DA 2 stated 400 ppm was not right concentration because the concentration was too strong.

On [DATE REDACTED], at 3:37 p.m., an interview was conducted with DA 4. DA 4 was asked to test the Quat sanitizer in

the sanitizer bucket. DA 4 stated Quat sanitizer range needed to be between 200 -300 ppm. DA 4 stated 400 ppm was not right because the sanitizer was too concentrated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 70 555330 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555330 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverside Postacute Care 8781 Lakeview Avenue 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 On [DATE REDACTED], at 3:59 p.m., an interview was conducted with DA 3. DA 3 was asked to demonstrate to check

the concentration of Quat sanitizer in the sanitizer bucket. DA 3 stated Quat sanitizer should be only in 200 Level of Harm - Minimal harm or ppm. potential for actual harm

On [DATE REDACTED], at 4:07 p.m., a concurrent observation and interview was conducted with CK 2. CK 2 was asked Residents Affected - Some to demonstrate to check the concentration of Quat sanitizer in the sanitizer bucket. CK 2 stated Quat sanitizer should be only in 200 ppm. CK 2 stated 200 - 400 was not right concentration.

On [DATE REDACTED], at 9:33 a.m., a phone interview was conducted with the RD. The RD stated Quat Sanitizer should be between 200 - 400 ppm. and all food service workers should know the concentration range.

A review of the facility's policy and procedure titled, QUATERNARY AMMONIA LOG POLICY, dated 2023, indicated, .POLICY .The concentration of the ammonium in the quaternary (Quat) sanitizer will be tested to ensure the effectiveness of the solution . Read instructions on quaternary container and the test strips for proper concentration, length of time the strip needs to be in contact with the solution .when testing for concentration

14. On [DATE REDACTED], at 9:59 AM, an interview was conducted with DA 1. DA 1 was asked to demonstrate how to clean used meal cart. DA 1 stated she used green bucket (soap and water) to clean the meal cart and then sanitize with sanitizer.

On [DATE REDACTED], at 3:59 PM, an interview was conducted with DA 3. DA 3 was asked to demonstrate how to clean used meal cart. DA 3 stated he only used sanitizer to clean the used meal cart.

On [DATE REDACTED], at 9:33 AM, an interview was conducted with the RD. The RD stated not using cleaning procedure with wash, rinse and sanitizer could result not properly sanitize the used meal cart which cause cross contamination and lead to food borne illness.

A review of the facility Policy and procedure (P&P) titled, SANITATION, dated 2023, the P&P indicated, . PROCEDURE: .4. Each employee shall know how to .clean all equipment .

A review of the facility's policy and procedure titled, SHELVES, COUNTERS, AND OTHER SURFACES INCLUDING .FOOD PREPARATION ., dated 2023, indicated, CLEANING PROCEDURE: 1. Remove any large debris and wash surface with a warm detergent solution .Rinse with clear water .Spray with a sanitizer .

15. On [DATE REDACTED], at 4:07 p.m., a concurrent observation and interview was conducted with CK 2. CK 2 was asked to demonstrate how to calibrate the thermometer used to check the temperature of the food to be served. CK 2 got a cup of ice filled with water and then put the thermometer inside. CK 2 stated he needed to calibrate the thermometer to 40 degrees Fahrenheit ( F - a unit of measurement).

On [DATE REDACTED], at 11:11 a.m., a concurrent observation and interview was conducted with DA 2. DA 2 was asked to demonstrate how to calibrate the thermometer. DA 2 got a cup of ice filled with water and then put

the thermometer inside. DA 2 stated she needed to calibrate the thermometer to 39 F.

On [DATE REDACTED], at 9:33 a.m., an interview was conducted with the RD and the FSN. The RD stated the thermometer needed to be calibrated to 32 F. The FSN stated the potential risk for thermometers which were not properly calibrated by the dietary staff when they check the food temperature could cause foodborne illnesses.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 70 555330 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555330 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverside Postacute Care 8781 Lakeview Avenue 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 A review of the facility's policy and procedure titled, THERMOMETER USE AND CALIBRATION, dated 2023,

the indicated, .Food thermometers are to be used properly and calibrated to ensure accurate temperature Level of Harm - Minimal harm or reading .If the thermometer does not read 32 F, then the thermometer must be calibrated or discarded . potential for actual harm

A review of the professional reference retrieved from the Centers for Disease Control and Prevention (CDC) Residents Affected - Some document titled, Food Safety, dated [DATE REDACTED], indicated, .Food is safely cooked when the internal temperature gets high enough to kill germs that can make you sick. The only way to tell if food is safely cooked is to use a food thermometer. You can't tell if food is safely cooked by checking its color and texture .Use a food thermometer to ensure foods are cooked to a safe internal temperature .

16. On [DATE REDACTED], a review of the manufacturer's guidelines for three compartment sink cleaning procedures posted above three compartment sink indicated, .Place items in Sanitizing Solution for 1 minute .

On [DATE REDACTED], at 3:37 p.m., an interview was conducted with DA 4. DA 4 was asked how long he need to submerge the washed kitchen ware in the sanitizer in the sanitizing sink. DA 4 was unable to answer the question.

On [DATE REDACTED], at 3:59 p.m., an interview was conducted with DA 3. DA 3 was asked how long he need to submerge the washed kitchen ware in the sanitizer in the sanitizing sink. DA 3 stated washed kitchen ware need to be submerged into the sanitizer for 10 seconds.

On [DATE REDACTED], at 9:33 a.m., an interview was conducted with the RD and the FSN. Both of the RD and the FSN stated they were unsure how long washed kitchen ware needed to be submerged into the sanitizer in the sanitizing sink.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 70 555330 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555330 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverside Postacute Care 8781 Lakeview Avenue 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 0814 Dispose of garbage and refuse properly.

Level of Harm - Minimal harm or 44504 potential for actual harm Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse Residents Affected - Many properly when trash and used gloves were found on the floor surrounding the dumpsters.

This failure had the potential to attract pests and cause infection control issue.

Findings:

On March 17, 2025, at 9:23 a.m., a concurrent observation and interview was conducted with the Food and Nutrition Services Director (FNS) outside the back kitchen at the dumpsters area. Food residual were observed on the grass near the entrance door of the kitchen. Trash and used gloves were found on the floor surrounding the dumpster area and gate area. The FNS stated the back kitchen area's floor need to be kept clean otherwise it would promote bacterial growth, attract pests, and it is infection control issue.

On March 20, 2025, at 9:33 a.m., a phone interview was conducted with the Registered Dietician (RD). The RD stated the outside back kitchen floor should be kept clean. The RD explained trash, used gloves and food residual could attract pests and had potential to cause infection control issue.

During a review of the facility's policy and procedure titled, MISCELLANEOUS AREAS, dated 2023, indicated, .GARBAGE AND TRASH .Trash Procedure .Garbage and trash cans must be inspected daily that no debris is on the ground or surrounding area, and that the lids are closed. TRASH COLLECTION AREA:

The trash collection area is a potential feeding ground for vermin and rodents and must be kept clean .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 70 555330 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555330 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverside Postacute Care 8781 Lakeview Avenue 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 0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Level of Harm - Minimal harm or potential for actual harm 50204

Residents Affected - Some Based on interview and facility record review, the facility failed to ensure a written Quality Assurance Performance Improvement (QAPI - a systematic, interdisciplinary, comprehensive, and data-driven approach to maintain and improve safety, quality of care, and quality of life of the residents) plan in place to address

the facility's systemic process issues related to staffing, dietary, and laundry services.

These failures resulted in multiple residents to not receive appropriate services from Certified Nursing Assistant (CNA) staffing, dietary, and laundry services. In addition, these failures had the potential to place other residents residing at the facility to be at risk for not achieving their highest physical, mental, psychosocial well-being.

Findings:

On March 17, 2025 to March 21, 2025, during the facility's recertification survey, systemic issues were identified with sufficient nursing staff (see findings under