Riverside Postacute Care

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

he was going to be at (sic) (name of Resident 168) .On September 12, 2025, at 11:38 am a concurrent

interview and record review were conducted with the AD. The AD stated he informed the Social Services Director (SSD) of Resident 10's refusal of headphones. The AD stated he did not know if any other interventions were implemented to address the loud volume.On September 12, 2025, at 1:10 pm, a concurrent interview and record review was conducted with the SSD. The SSD stated the Grievance Report dated June 12, 2025, addressed the issue by removing the complainant and did not address the loud volume. On September 12, 2025, at 2:46 p.m., an interview was conducted with Licensed Vocational Nurse (LVN) 3. LVN 3 stated if there was a complaint about loud music it should be addressed and care planned.

LVN 3 stated it was important to know what interventions should be implemented to address the problem.On September 12, 2025, at 2:48 pm an interview was conducted with the Director of Nursing (DON). The DON stated she was aware of the grievance filed in June and the behavior of the resident (Resident 10) should have been addressed. The DON stated a care plan should have been initiated to implement interventions. The DON stated on August 17, 2025, the resident (Resident 10) played his music loudly, which led to a verbal altercation between the two residents (Resident 10 and Resident 168). The DON stated if there was an intervention or care plan, the altercation on August 17, 2025, could have been prevented.A review of the facility's policies and procedures titled, Abuse and Neglect Prohibition Policy, dated June 2022, indicated, .The following actions to prevent abuse.identifying, correcting, and intervening

in situations in which abuse.is more likely to occur.care planning.of residents with needs and behaviors which might lead to conflict.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/12/2025

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 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

Based on interviews and record reviews, the facility failed to complete monitoring for a skin related change of condition for one of one resident (Resident 12) reviewed for quality of care.This failure resulted in inconsistent evaluation of the wound and placed Resident 12, who had diabetes (abnormal blood sugar) and peripheral vascular disease (a problem with blood flow), at risk for infection, delayed wound treatment, and worsening of the condition of the left second toe.Findings:A review of Resident 12's admission Record dated September 10, 2025, indicated an admission date of July 20, 2025 with a diagnoses which included peripheral vascular disease and diabetes mellitus.A review of Resident 12's History and Physical dated August 25, 2025, indicated resident can make needs known but cannot make medical decisions.A review of Resident 12's Minimum Data Set (MDS - an assessment tool) dated September 2, 2025, indicated a Brief

Interview for Mental Status (BIMS - a tool to assess cognitive function) score was 05 (severe cognitive impairment).A review of Resident 12's Podiatric Evaluation and Treatment Report dated August 18, 2025, indicated .Peripheral Arterial Disease.Trimmed and electrical Debridement with Dremel drill.Nail removal.Left.T1 Avulsion (tearing of body part)/Removal.A review of Resident 12's N Adv - Skin Check dated August 18, 2025, indicated, .Left Dorsum 2nd Digit (Second Toe).description.Avulsion.new wound.onset.New.A review of Resident 12's N Adv - Skilled Evaluation dated August 19, 2025, and August 21, 2025, indicated, .Skin Group.no skin issues.On September 10, 2025, at 12 p.m., a concurrent interview and record review was conducted with the Treatment Nurse (TN). The TN stated Resident 12's skin avulsion

on the left second toe was a new skin finding and should have been considered a change of condition. The TN further stated a change of condition should have been documented and monitored to track the progress of the wound.On September 12, 2025, at 10:58 a.m. an interview was conducted with the Director of Nursing (DON). The DON stated the left second toe avulsion was caused by the podiatry treatment on August 18, 2025. The DON stated a change of condition should have been completed right away including monitoring every shift for three days, to determine if the wound is improving or deteriorating.A review of the facility policy and procedure titled, Change in a Resident's Condition or Status, dated January 2018, indicated, .A ‘significant change' of condition.requires interdisciplinary review.The nurse will record.information relative to changes in the resident's medical.condition or status.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet