Health inspection·November 4, 2024

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their grievance policy and procedure for one resident, (Resident 1) when the family representative (FR) expressed concerns about Resident 1 ' s care. This failure may have contributed to a delay in response to verbal concerns submitted on behalf of Resident 1. Findings: On October 9, 2024, a review of Resident 1 ' s Electronic Records (ER-systematized collection of patient and population electronically stored health information in digital format) was conducted. Resident 1 was admitted on [DATE], with diagnoses including major depressive disorder (common mental health condition that impacts how a person feels and thinks), Parkinsonism (general term for a group of brain conditions, causes stiffness and slowed movement), and dementia (a group of disease characterized by memory loss). Resident 1 ' s history and physical, dated August 27, 2024, indicated Resident 1 did not have capacity to make decisions. A review of Resident 1's Order Summary Report, included a physician's order, dated October 1, 2024, which indicated an order for wound treatment to the right forearm to cleanse with NS (normal saline- sterile solution of water and salt), pat dry, apply triple antibiotic (combination of antibiotics to treat and prevent minor bacterial skin infections) every day shift for 14 days. On October 9, 2024, at 9:50 a.m., an observation and interview with Resident 1 was conducted. Resident 1 was observed lying in bed clothed and agreed to interview. Resident 1 was observed to have bilateral arms with old scabs and multiple discoloration. Resident 1 had his left forearm with bandage wrapped. In a concurrent Interview with Resident 1, he stated two people were holding him and he thought they were mad at him. Resident 1 stated he could not remember the day it happened and he stated he did not feel safe because he did not know why they held him and hurt him at that time. On October 9, 2024, at 11:47 a.m. an interview with the Family Representative (FR) was conducted. The FR stated another family member received a call on October 1, 2024, from a Licensed Vocational Nurse (LVN) stating that Resident 1 sustained a wound on his right arm while struggling and hit his arm with the staff arm. The FR stated she was told the injury was from an arm-to-arm contact. She stated she got concern when she saw all the steri-strips (thin strips of tape put across an incision or minor cut) on the wound. She stated she spoke with the (DON) and called her attention to Resident 1 (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: 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 11/04/2024 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)