Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0689
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Level of Harm - Actual harm
Residents Affected - Few
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, for one of three residents reviewed (Resident A), the facility failed to ensure
the effectiveness of the interventions to prevent falls were evaluated, and new interventions were
implemented to address Resident A ' s repeated falls due to behavior of getting up unassisted and prevent
further falls.
These failures resulted in Resident A to have 16 falls from October 16, 2023, to February 13, 2024, while at
the facility. Resident A ' s fifth (5th) fall resulted to the resident to sustain a laceration (cut) on the back of
his head and was treated in the emergency room (ER) with two staples (used to close wounds) placed on
the laceration. Resident A ' s ninth (9th) fall resulted to the resident to sustain a skin tear on the right elbow.
Resident A ' s 15th fall resulted to the resident to be transferred to the acute hospital and sustained multiple
left rib fractures (broken bone) and thoracic compression fractures (a break in a bone in the middle section
of the spine).
Findings:
On August 5, 2024, at 8:54 a.m., an unannounced visit was conducted at the facility to investigate a
complaint regarding quality of care and accidents.
A review of Resident A's admission Record, indicated Resident A was initially admitted to the facility on
[DATE], with diagnoses which included spinal stenosis (spaces inside the bones of the spine get too small),
chronic atrial fibrillation (irregular heart beat that causes poor blood flow), emphysema (lung disease),
history of falling, difficulty walking, and alcohol dependence.
A review of Resident A's Fall Risk Observation/Assessment, dated October 12, 2023, indicated a score of
26 (high risk for falls score of 16-42).
A review of Resident A's care plan, developed on October 12, 2023, indicated, .Falls: Resident is at risk for
falls with or without injury related to impaired safety awareness due to episodes of confusion and
forgetfulness, history of falls, hx (history) of alcohol dependence, anxiety, multiple medications, and hx of
vertigo (a sensation in which you feel as though you are moving, spinning, or off balance) .Goal .Will have
no serious injury til (sic) next review .Interventions/Tasks .Anticipate and meet needs .Educate/remind
resident to call for assistance with all transfers .keep call light within reach and reorient during routine care
.keep bed to lower position .keep personal items within reach .PT/OT (physical therapy/occupational
therapy) eval (evaluation) as indicated .
A review of Resident A's Minimum Data Set (MDS- a standardized comprehensive assessment and care
(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 10
Event ID:
055581
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
055581
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/11/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Jurupa Hills Post Acute
6401 33rd Street.
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 0689
planning tool), dated February 29, 2024, indicated the following:
Level of Harm - Actual harm
- Resident A had a Brief interview for Mental Status (BIMS -a tool used to screen and identify cognitive
[process of thinking] condition of residents) score of 3 (severe cognitive impairment); and
Residents Affected - Few
- Resident A required moderate to maximum assistance with ADL ' s (activities of daily living includes
bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet and eating).
Further review of Resident A's documents indicated the resident had multiple falls during his stay at the
facility as follows:
1. A review of Resident A's Change of Condition Evaluation, dated October 16, 2023, at 1:26 p.m.,
indicated, .resident found on floor near bed on both knees @ (at) 0930 (9:30 a.m.). pt (patient) awake and
alert c/o (complain of) left rib pain. no redness or any discoloration noted to site. denies pain to touch. fall
matts beside bed and call light noted within reach. MD (doctor) notified .
A review of Resident A's Post Fall Review, dated October 16, 2023, indicated, Unable to independently
come to a standing position, exhibits loss of balance while standing, Strays off the straight path of walking,
requires hands-on assistance to move from place to place, uses short discontinuous steps and/or shuffling
steps, Changes gait pattern when walking through doorways, has lurching, swaying, or slapping gait .
A review of Resident A's care plan, dated October 17, 2023, included additional interventions which
indicated, .encourage and assist to activity to keep self-occupied .move to room closer to nursing station .
A review of Resident A's Interdisciplinary Team (IDT-staff from different health care disciplines discuss to
help people receive the care they need) Notes, dated October 17, 2023, indicated, .resident was not able to
explain what happened not explained what he was trying to do due to resident with episodes of confusion
and forgetfulness .
2. A review of Resident A's Change of Condition Evaluation, dated November 10, 2023, at 6:54 p.m.,
indicated, .Resident was in hallway trying to sit in his wheelchair when the wheelchair rolled away and
resident fell and landed on buttock. He did not hit his head and does not c/o any pain or discomfort at this
time. MD notified and his order was to monitor patient for now .
A review of Resident A's Post Fall Review, dated November 10, 2023, indicated, .Exhibits loss of balance
while standing, requires hands-on assistance to move from place to place, uses as assistive device, e.g.
(example) cane, walker, etc.
A review of Resident A's care plan, dated November 10, 2023, included additional interventions which
indicated, .PT/OT (physical therapy/occupational therapy) focusing on wheelchair mobility, application of
brakes, redirection, assist with verbal cues
Further review of Resident A's medical record did not indicate IDT notes after the Resident A's fall on
November 10, 2023.
3. A review of Resident A's Progress Notes, dated November 14, 2023, at 7:35 p.m., indicated, .At
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055581
If continuation sheet
Page 2 of 10
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
055581
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/11/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Jurupa Hills Post Acute
6401 33rd Street.
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 0689
Level of Harm - Actual harm
Residents Affected - Few
1530 (3:30 p.m.), Resident had an unwitnessed fall in the unit hallway. Resident stated he was attempting
to get up to get coffee and forgot to lock his wheelchair. Resident stated he hit his head and complained of
pain 7/10 (severe pain). Resident was assisted by 2 person back into wheelchair and educated on risks and
benefits of noncompliance with ADLs. MD was notified, RP (responsible party) notified. MD (doctor)
recommended to send to hospital due to patient being on blood thinner .
Further review of Resident A's medical record did not indicate a Post Fall Review and IDT notes were
completed after Resident A had a fall on November 14, 2023.
4. A review of Resident A's Progress Notes, dated November 20, 2023, at 9:15 p.m., indicated, Staff
reported res (resident) fell on the hallway. Res attempting to sit down without locking the wheelchair first.
Res fell back and hit the head. Res is awake, alert with confusion as res baseline .Staff assisted res to bed.
Body assessment no injury noted. Res denies any headache or dizziness. No redness or swelling. Denies
any pain or discomfort . Educated res to call nurse for assistance and remind res to lock the wheelchair
prior sitting on the w/c (wheelchair) .
A review of Resident A's Change of Condition Evaluation, dated November 20, 2024, at 9:27 p.m.,
indicated, .resident is noncompliant with asking for help and insist on ambulating on his own .
Further review of Resident A's medical record did not indicate a Post Fall Review and IDT notes were
completed to reflect new interventions after Resident A had a fall on November 20, 2023.
5. A review of Resident A's Change of Condition Evaluation, dated November 28, 2023, at 7:32 a.m.,
indicated, .Resident was on the floor at the foot of the bed holding on to the back of his head. Upon
assessing resident, he had a minor cut on the back of his head that was bleeding .
A review of Resident A's Progress Notes, dated November 28, 2023, at 7:35 p.m., indicated, .At 19:20 (7:20
p.m.,), resident returned from (name of hospital) after being treated for laceration (cut) to scalp, had 2 (two)
staples inserted to be removed in 7-10 days, keep dry for first 2 (two) days. Resident appears drowsy with
slurred (not clear) speech .bed at lowest position, call light within easy reach .
A review of Resident A's Change of Condition Evaluation, dated November 28, 2023, at 11:38 p.m.,
indicated, .patient is noncompliant with asking staff for help. Resident has been educated multiple times. He
understands and still chooses to walk without assistance .
A review of Resident A's Progress Notes, dated November 28, 2023, at 11:38 p.m., indicated, .Resident
found on floor by staff. Resident refused help from staff, attempting to strike nurses. Resident was assisted
back to bed, MD, DON (Director of Nursing), and RN (Registered Nurse) notified immediately .
Further review of Resident A's medical record did not indicate a Post Fall Review and IDT notes were
completed after Resident A fell on November 28, 2023.
A review of Resident A's care plan, dated November 28, 2023, included additional interventions which
indicated, .move to room closer to nursing station with minimal stimulation due to noise on the surrounding
area and made him restless and agitated when being redirected for safety .
6. A review of Resident A's Change of Condition Evaluation, dated December 5, 2023, at 12:15 a.m.,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055581
If continuation sheet
Page 3 of 10
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
055581
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/11/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Jurupa Hills Post Acute
6401 33rd Street.
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 0689
Level of Harm - Actual harm
indicated, .resident found sitting on floor at bedside, leaning on right side against his bed, body assessment
and neuro checks (to check mental status and speech) performed .no visible injuries at time .he stated that
he was trying to go to the bathroom and he fell down .Noncompliant with fall prevention, not utilizing call
light, constantly attempts to get off bed unaided .
Residents Affected - Few
A review of Resident A's Post Fall Review, dated December 6, 2023, indicated, .Exhibits loss of balance
while standing, strays off the straight path of walking, requires hands-on assistance to move from place to
place, uses an assistive device, e.g. cane, walker, etc .
Further review of Resident A's medical record did not indicate IDT notes and new interventions were placed
after resident had a fall on December 5, 2023.
7. A review of Resident A's Change of Condition Evaluation, dated December 9, 2023, at 6:30 p.m.,
indicated, .CNA (certified nursing assistant) was helping resident to use restroom. while getting resident
back on wheelchair resident lost balance and fell on his right side. CNA and resident denied hitting head.
resident c/o pain to right side of hip resident encouraged to stay in w/c and ask for assistance when needed
.
A review of Resident A's hip x-ray, dated December 12, 2023, indicated bilateral hips no fractures .minor
degenerative changes (a progressive loss of structure or function in tissues or organs identified .
Further review of Resident A's medical record did not indicate a Post Fall Review and IDT notes were
completed and no new interventions were implemented after resident had a fall on December 9, 2023.
. A review of Resident A' s Change of Condition Evaluation, dated December 14, 2024, at 10:45 p.m.,
indicated, .Resident stated he attempted to go to the restroom and fell. Resident verbalized pain to buttocks
and head. RN assessed resident and no apparent dislocation (a separation of two ends of the bones where
they meet at a joint). or visible injuries. Resident was assisted to the wheelchair and then back to the bed
.resident noted to have pain to buttocks and head .
A review of Resident A's Post Fall Review, indicated, .Exhibits loss of balance while standing, strays off the
straight path of walking, requires hands-on assistance to move from place to place, uses an assistive
device, e.g. cane, walker, etc .
Further review of Resident A's medical record did not indicate IDT notes and new interventions were placed
after resident had a fall on December 14, 2023.
9. A review of Resident A's Change of Condition Evaluation, dated December 20, 2023, at 3:31 p.m.,
indicated, .Resident attempted to stand on his own, upon standing resident witnessed to have tripped over
footrest and land on right side next to wheelchair. Head to toe assessment rendered, small skin tear
1.5x1.2cm (centimeters - unit of measurement) to right elbow noted. MD made aware .72-hour neurochecks
.
A review of Resident A's care plan, dated December 20, 2023, included additional intervention to remove
wheelchair footrest.
Further review of Resident A's medical record did not indicate a Post Fall Review and IDT notes were
completed after Resident A fell on December 20, 2023.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055581
If continuation sheet
Page 4 of 10
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
055581
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/11/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Jurupa Hills Post Acute
6401 33rd Street.
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 0689
Level of Harm - Actual harm
10. A review of Resident A's Change of Condition Evaluation, dated December 23, 2023, at 7:30 p.m.,
indicated, .Resident observed trying to sit in wheelchair when he tripped on sneaker. He is alert, able to
move all limbs, denies any pain, did not hit head, fell on right shoulder .
Residents Affected - Few
A review of Resident A's Post Fall Review, dated December 23, 2023, indicated,
.Exhibits loss of balance while standing, requires hands-on assistance to move from place to place, uses
an assistive device, e.g. cane, walker, etc., decrease in muscle coordination .
A review of Resident A's care plan, dated December 23, 2023, indicated additional intervention for Resident
A to wear proper footwear and provide slip on shoes without string .
Further review of Resident A's medical record did not indicate IDT notes was completed after resident had
a fall on December 23, 2024.
11. A review of Resident A's Change of Condition Evaluation, dated December 25, 2023, at 1:50 p.m.,
indicated, .Resident noted to have unwitnessed fall. CNA passing the hallway noted that the resident was
on the floor next to his bed laying on his back. Resident noted to have unwitnessed fall wearing nonskid
socks. Resident noted to have pull pants down and a recently soiled brief .no complain of pain. Resident
denies hitting his head and noted to have a minor scrape to right forearm no bleeding noted. Neuro checks
started and patient assisted back to bed .
A review of Resident A's Post Fall Review, dated December 25, 2023, indicated, .Unable to independently
come to a standing position, exhibits loss of balance while standing, strays off the straight path of walking,
requires hands-on assistance to move from place to place, uses short discontinuous steps and/or shuffling
steps, has lurching, swaying, or slapping gait, wears poorly fitting shoes .
Further review of Resident A's medical record did not indicate IDT notes and no new interventions were
implemented after resident had a fall on December 25, 2023.
12. A review of Resident A's Change of Condition Evaluation, dated December 30, 2023, at 4:00 p.m.,
indicated, .Was called to Nurses station, on assessment, resident seen sitting on floor, stated he was trying
to get up and fell to the floor, fall was unwitnessed by staff .Patient is alert, can move all limbs, no visible
injuries noted .
A review of Resident A's Post Fall Review, dated December 30, 2023, indicated,
.Exhibits loss of balance while standing, requires hands-on assistance to move from place to place,
decrease in muscle coordination .
A review of Resident A's care plan, dated December 31, 2023, indicated additional intervention to apply
pad alarm (wireless emergency alert placed on the resident).
Further review of Resident A ' s medical record did not indicate IDT notes was completed after the resident
had a fall on December 30, 2023.
13. A review of Resident A's Change of Condition Evaluation, dated January 8, 2024, at 6:59 a.m.,
indicated, .the resident is trying to stand up from the wheelchair. CNA and LVN (Licensed Vocational Nurse)
keep telling the resident to stay but he never listen (sic) and he lose (sic) his balance
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055581
If continuation sheet
Page 5 of 10
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
055581
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/11/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Jurupa Hills Post Acute
6401 33rd Street.
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 0689
standing up and fell on the floor .
Level of Harm - Actual harm
A review of Resident A's care plan, dated January 8, 2024, indicated additional intervention to ambulate
with handheld assist when trying to get up and not being redirected, and assist up in chair and keep by
nursing station for immediate visual monitoring when restless in bed.
Residents Affected - Few
Further review of Resident A's medical record did not indicate a Post Fall Review and IDT notes were
completed after Resident A fell on January 8, 2024.
14. A review of Resident A's Change of Condition Evaluation, dated January 11, 2024, at 4:29 a.m.,
indicated, .Was called into resident's room re: fall. On assessment resident seen lying on floor out on
hallway in supine (lying face upward) position with knees drawn up. CNA verbalized that he was trying to
grab a bottle off nurses desk when he stumbled, fell backwards, hitting head against door frame. Neuro
checks performed, is able to state name and move all limbs, c/o having headache and back pain .
A review of Post Fall Review, dated January 11, 2024, indicated, .Unable to independently come to a
standing position, exhibits loss of balance while standing, strays off the straight path of walking, requires
hands-on assistance to move from place to place, uses short discontinuous steps and/or shuffling steps,
exhibits jerking or instability when making turns .
A review of Resident A's care plan, dated January 14, 2024, indicated for resident to be placed in a merry
walker (a mobility aid that combines the features of a walker and a wheelchair, allowing users to walk
independently and safely) when up and out of bed.
Further review of Resident A's medical record did not indicate IDT notes after resident had a fall on January
11, 2024.
15. A review of Resident A's Change of Condition Evaluation, dated February 2, 2024, at 12:44 p.m.,
indicated, .Loud noise heard down the hallway. Resident was found on floor in room next to bed A. RN
notified. Resident assessed by charge nurse and RN resident assisted to side of bed. resident observed to
be holding back of head and forehead. Resident unable to state how he fell .
A review of Resident A's Post Fall Review, dated February 2, 2024, indicated, .Exhibits loss of balance
while standing, strays off the straight path of walking, requires hands-on assistance to move from place to
place, uses short discontinuous steps and/or shuffling steps, changes gait pattern when walking through
doorways, has lurching, swaying, or slapping gait, exhibits jerking or instability when making turns, wears
poorly fitting shoes .
A review of the facility document titled, Transfer Form, dated February 2, 2024, at 2:57 p.m., indicated
Resident A was transferred to the general acute hospital (GACH).
A review of Resident A ' s GACH document titled, History of Present Illness, dated February 2, 2024,
indicated, .on Eliqius (medication to thin the blood) presenting from his nursing care facility for ground level
fall when he fell off his bed hitting his head .
A review of Resident A's radiology report for CT (Computerized Tomography - a medical imaging procedure
that uses x-rays to create detailed images of the body) of the Lumbar Spine (lower back region of spine)
Region, dated February 2, 2024, indicated, .Subacute (happened about 5 to 14 days) to
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055581
If continuation sheet
Page 6 of 10
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
055581
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/11/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Jurupa Hills Post Acute
6401 33rd Street.
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 0689
Level of Harm - Actual harm
chronic (old) 6-9 (rib fractures) left lateral fractures .There is 10% superior endplate vertebral (round, thick,
weight-bearing bones in the spine) body height loss at T1 and T2 (first two bones in the middle part of the
spine) .These may represent acute (new) to subacute compression fractures[EC12] (a break in a bone in
the spine that collapses) .
Residents Affected - Few
A review of Resident A's GACH document, dated February 5, 2024, indicated, .plan .remains at risk to fall
again. Would not leave a wheelchair by his bedside with this being his primary mobility prior to his fall and
injury .
A review of Resident A's IDT Notes, dated February 5, 2024, indicated IDT discussed resident condition
and director of nursing assess resident upon returned from hospital and no change in mental status noted,
no external trauma including any open skin not discoloration noted, no tenderness no swelling noted. IDT
discuss plan of care and to continue currently in place .
A review of Resident A's care plan related to the fall incidents from October 16, 2023, to February 5, 2024,
included the following interventions:
- keep resident clean and dry;
- maintain hazard free environment;
- proper footwear;
- keep frequently use personal items within reach;
- assist with needs as anticipated and as needed;
- lowest bed position; floor mats when in bed;
- assist to activity to keep self-occupied;
- room closer to the nursing station for immediate and frequent visual check; and
- taken for a walk within the facility and outside patio when restless, provide simple activity book, and other
noncomplicated activity when up in the chair to keep self-busy, assist with needs as anticipated and as
needed.
16. A review of Resident A's Change of Condition Evaluation, dated February 13, 2024, at 2:26 p.m.,
.Resident was sitting in wheelchair in front of station. Writer turned away from med (medication) cart. Writer
heard loud bang, resident found sitting on floor against the wall in front of station, resident holding back of
head. RN made aware and assessed resident .
A review of Resident A's Progress Notes, dated February 13, 2024, indicated, .@ (at)approx.
(approximately) 1300 (1:00 p.m.) Resident was sitting in wheelchair in front of station. Writer turned away
from med cart. Writer heard loud bang, resident found sitting on floor against the wall in front of station,
resident holding back of head. RN made aware and assessed resident .Resident assisted back into bed by
charge nurse and assigned CNA .MD made aware .orders for CT scan of head and spine. MD made aware
that CT are not done in facility. MD agreed .send to (name of GACH) .
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055581
If continuation sheet
Page 7 of 10
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
055581
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/11/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Jurupa Hills Post Acute
6401 33rd Street.
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 0689
Level of Harm - Actual harm
Residents Affected - Few
A review of Resident A's IDT Notes, dated February 14, 2024, at 3:43 p.m., indicated, On 2/13/2024
(February 13, 2024) at approx. (approximately) 1300 (1:00 p.m.,) patient was found sitting on buttock with
back facing the wall. Patient was holding back of head, complains of slight pain. Nurse notified MD and
patient was sent to acute care hospital for further observation. IDT interviewed nurse that was in care of
patient at the time of fall. Nurse stated that patient had been monitored at nursing station majority of the
early afternoon, she stated she turned around to print something (still standing at station) and when she
turned around patient was sitting on the floor .
On August 5, 2024, at 2:16 p.m., during an interview LVN 2, he stated Resident A was alert and oriented to
his name and place. LVN 2 stated the staff would assist him in the seat but would get up right away. LVN 2
stated Resident A's mobility was limited and had to keep an eye on him constantly, even if staff turned for a
second, Resident A could get up. LVN 2 stated Resident A would take off the alarm from the wheelchair
and tried to break the cord because the resident did not like the sound. LVN 2 stated Resident A had
multiple falls and a 1:1 (staff assigned only to one resident to prevent falls) sitter was not used all the time.
LVN 2 also stated Resident A's falls could have been prevented if he had a 1:1 sitter.
On August 5, 2024, at 2:52 p.m., during a concurrent interview and record review of Resident A's therapy
notes with the Director of Rehabilitation (DOR) and the Physical Therapist (PT), the PT stated Resident A
was not steady on his feet and was high risk for falls, and had no dynamic balance (ability to remain
standing and be stable). The DOR stated a reassessment was completed after every fall and if there were
no changes, and continued with the therapy goals.
On August 5, 2024, at 3:55 p.m., during concurrent interview with the Director of Nursing (DON), the DON
stated the residents were being assessed for falls upon admission, quarterly, annually and when the
resident had a change of condition. The DON stated Resident A had a history of dementia (cognitive
impairment with memory loss) had interventions in place to address risk for falls but Resident A would get
up constantly. The DON stated most of Resident A ' s falls were from the edge of the bed and a complete
fall risk assessment was done and discussed with the IDT team and interventions to monitor the resident.
On August 13, 2024, at 9:26 a.m., during a concurrent interview and record review of Resident A's post fall
review with the DON, she stated a Post Fall Review should be completed by nursing after every fall. The
DON stated Post Fall Reviews were not completed for the following dates:
- November 14, 2023, after the third fall;
- November 20, 2023, after the fourth fall;
- November 28, 2023, after the fifth fall;
- December 9, 2023, after the seventh fall;
- December 20, 2023, after the ninth fall;
- January 8, 2024, after the 13th fall; and
- February 13, 2024, after the 16th fall.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055581
If continuation sheet
Page 8 of 10
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
055581
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/11/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Jurupa Hills Post Acute
6401 33rd Street.
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 0689
Level of Harm - Actual harm
The DON stated IDT meetings were to be held to discuss a resident ' s plan of care after a fall incident. The
DON stated an IDT meeting was held after each of Resident A's falls and the plan was discussed with the
team, but there was no documentation in Resident A ' s medical record. The DON stated the IDT notes
were not completed to address each of Resident A's fall incidents on the following dates:
Residents Affected - Few
- November 10, 2023, after the 2nd fall;
- November 14, 2023, after the third fall;
- November 20, 2023, after the fourth fall;
- November 28, 2023, after the fifth fall;
- December 5, 2023, after the sixth fall;
- December 9, 2023, after the seventh fall;
- December 14, 2023, after the eighth fall;
- December 20, 2023, after the ninth fall;
- December 23, 2023, after the 10th fall;
- December 25, 2023, after the 11th fall;
- December 30, 2023, after the 12th fall;
- January 8, 2024, after the 13th fall;
- January 11, 2024, after the 14th fall; and
- February 13, 2024, after the 16th fall.
The DON stated they did a trial for Resident A to use the merry walker but was not implemented thereafter
as was not working for the resident after the 14th fall. The DON stated the staff on the unit took turns to
watch Resident A, but a 1:1 sitter was not assigned to him despite the multiple falls. The DON stated if a 1:1
staff was assigned to Resident A, it could have minimized the repetitive falls because most of the falls were
a result of Resident A trying to get up unassisted. The DON stated Resident A's multiple falls were not
properly evaluated to address the cause of the fall and implement appropriate interventions to prevent
injuries and repeat falls.
A review of facility's policy and procedure titled, Falls-Clinical Protocol with a revision date of [DATE],
indicated, .physician will help identify individuals with a history of falls and risk factors for subsequent falling
.risk factors for subsequent falling include .musculoskeletal (related to muscles and bones) abnormalities
.gait and balance disorders, cognitive impairment, weakness .confusion .the physician will identify medical
conditions affecting fall risk .and the risk for significant complications of falls .Cause Identification .after a
first fall, the staff .should watch the individual rise from a chair without using his or her arms, walk several
paces and return not sitting
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055581
If continuation sheet
Page 9 of 10
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
055581
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/11/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Jurupa Hills Post Acute
6401 33rd Street.
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 0689
Level of Harm - Actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
.if the individual has difficulty or is unsteady in performing this test, additional evaluation should occur
.Treatment/Management .the staff and physician will identify pertinent interventions to try to prevent
subsequent falls and to address risks of serious consequences of falling .Monitoring and Follow-Up the
staff, with the physician ' s guidance, will follow up on any fall with associated injury until the resident is
stable .the staff and physician will monitor and document the individual ' s response to interventions
intended to reduce falling or the consequences of falling .
Event ID:
Facility ID:
055581
If continuation sheet
Page 10 of 10
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
FAQ · About this visit
Common questions about this visit
What happened during the September 11, 2024 survey of JURUPA HILLS POST ACUTE?
This was a inspection survey of JURUPA HILLS POST ACUTE on September 11, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at JURUPA HILLS POST ACUTE on September 11, 2024?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.