Inspection·May 9, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure bilateral floor mats were in place for one of three residents reviewed, (Resident 3). This failure had the potential to increase the risk for injury during an incident of fall for Resident 3. Findings: On March 29, 2023, at 11:30 a.m., an unannounced visit to the facility was initiated for a complaint investigation. On March 29, 2023, at 1:56 p.m., observed Resident 3 in bed on her back. The bed was in the lowest position, and she had a floor mat on the left side of the bed. On March 29, 2023, at 2:33 p.m., an interview was conducted with the Certified Nursing Assistant, (CNA). The CNA stated Resident 3 was a fall risk, and floor mats should be on both sides of the bed. On March 29, 2023, at 2:44 p.m., an interview was conducted with the Licensed Vocational Nurse, (LVN 1). LVN 1 stated floor mats are supposed to be on both sides of the bed. LVN 1 stated Resident 3 only had one floor mat and did not know why it was only on one side. On March 29, 2023, at 2:56 p.m., an interview was conducted with LVN 2. LVN 2 stated floor mats are required on each side of the bed. A record review of Resident 3 ' s medical records indicated she was admitted on [DATE], with diagnoses of Polyosteoarthritis, (related to the process of aging, as water content of body cartilage increases, and the protein makeup of cartilage degenerates), stroke, dementia, (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning),bipolar disorder, (a mental health condition that causes extreme mood swings that include emotional highs and lows), and hypothyroidism, (a condition resulting from decreased production of thyroid hormones). A review of Resident 3 ' s Fall Risk Evaluation dated January 14, 2023, at 1:28 p.m., indicated she was at risk for falls. A review of Resident 3 ' s Care Plan initiated August 18, 2022, indicated Focus .The resident is at (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055042 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alta Vista Healthcare & Wellness Centre 9020 Garfield Street Riverside, CA 92503 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)