Health inspection·December 9, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an allegation of abuse was reported to the State survey agency within two hours for two of five residents, (Residents 2 and 3).This failure had the potential for a delay in the investigations and interventions to prevent further incidents of abuse. Findings:On December 9, 2025, at 10:14 a.m., an unannounced visit to the facility to investigate an allegation of physical abuse. A review of Resident 2's medical record indicated the resident was admitted on [DATE], with diagnoses of 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) and pressure ulcer injury stage 4 (PUI - full thickness tissue loss with exposed bone, tendon, or muscle).A review of Resident 2's History and Physical dated September 22, 2025, indicated resident was not capable of understanding and making decisions.A review of Resident 3's medical record indicated the resident was admitted on [DATE], with diagnoses of chronic obstructive pulmonary disease, (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), polyneuropathy, (the simultaneous malfunction of many peripheral nerves throughout the body), and depression, (a mood disorder that causes a persistent feeling of sadness and loss of interest).A review of Resident 3's History and Physical dated November 8, 2025, indicated resident had the capacity to make decisions.On December 9, 2025, at 11:52 a.m., during an observation of Resident 2, the resident was lying in bed on his right side, with eyes slightly opened, respirations were even and unlabored. Resident 2 did not respond to verbal questions. On December 9, 2025, at 12:18 p.m., during an interview with the Licensed Vocational Nurse (LVN 1), LVN 1 stated that Resident 2 was occasionally awake and could not be able to get out of bed. LVN 1 stated allegations of abuse should be reported to the Administrator, Director of Nursing within two hours. LVN 1 stated that an allegation of abuse would require keeping residents apart, physician notification, documentation of a change in condition, and care plan updates. On December 9, 2025, at 12:32 p.m., during an interview with Resident 3, Resident 3 stated that back in November 2025, Resident 2 reached toward the television remote and toward his bed, so he flicked Resident 2 on the head. Resident 3 stated there were no witnesses to the event. On December 9, 2025, at 1:01 p.m., during an interview with Licensed Vocational Nurse (LVN 2), LVN 2 stated that if a resident flicked another resident in the head, she would report the incident right away to the Registered Nurse, the abuse coordinator. A review of Resident 3's Progress Notes dated November 23, 2025, at 8 a.m., indicated Resident hit another resident on the head for being too noisy. Client educated on the importance of hitting or coming into contact with another resident. Resident reported he is lucky I didn't kick his ass. Resident again educated. Resident reported he flick the other resident on the head to quiet him.Further review of Resident 3's Progress Notes dated November 23, 2025, indicated no documentation that the alleged incident was reported to the California Department of Public Health (CDPH) within two hours. On December 9, Page 1 of 2 056162 056162 12/09/2025 Extended Care Hospital of Riverside 8171 Magnolia Avenue Riverside, CA 92504

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2025, at 3:01 p.m., during an interview with the Director of Nursing (DON), the DON stated that on December 1, 2025, the Social Service Director notified him of the November 23, 2025, incident at 8 a.m. The DON confirmed that the incident was considered an allegation of physical abuse and should have been reported within two hours to the CDPH. The DON stated that the incident was not reported within the required timeframe.On December 18, 2025, at 12:38 p.m., during a telephone interview with the Social Service Director (SSD), the SSD stated on December 1, 2025, she was reviewing Resident 3's progress notes, and noted the incident on November 23, 2025, at 8 a.m., and notified the DON. The SSD stated that the incident was reported to the state survey agency on December 1, 2025 (seven days after the incident). On December 18, 2025, at 12:51 p.m., during a telephone interview with LVN 3, LVN 3 stated that on November 23, 2025, at 8 a.m., a certified nursing assistant reported that there was an incident with Resident 3 and Resident 2. LVN 3 stated that during an interview with Resident 3, Resident 3 admitted flicking Resident 2 on the head. LVN 3 stated Resident 2 had no injuries from the incident. LVN 3 stated she was not aware that allegations of abuse were required to be reported within two hours. A review of Resident 2's eINTERACT SBAR Summary for Providers dated December 1, 2025, at 12:06 p.m., indicated The Change In Condition/s reported on this CIC Evaluation are/were. Resident's room mate (sic) allegedly flicked his head on 11/23/2025. He is safe with no injuries. No concerns or worries. room mate's (sic) bed moved to another room. MD and family aware. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: - Continue with POC.A review of Resident 3's eINTERACT SBAR Summary for Providers dated December 1, 2025, at12:45 p.m., indicated Situation: The Change In Condition/s reported on this CIC Evaluation are/were. Alleged physical aggression, flicking roommates head with his fingers one time. This happened on 11/23/25 and was documented but not reported. Resident room changed for his safety and that of room mates (sic) on 12/1/2025. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Continue monitoring- Psych consult.A review of the facility's policy and procedure titled Compliance with Reporting Allegations of Abuse/Neglect/Exploitation revised December 19, 2022, indicated .Reporting/Response: The facility will report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required, and take all necessary corrective actions depending on the results of the investigation.When suspicion of abuse/neglect/exploitation or reports of abuse/neglect/exploitation occur, the following procedure will be initiated.1. The Licensed Nurse will:a. Respond to the needs of the resident and protect him/her from further incident.b. Remove the accused employee from resident care areas.c. Notify the Administrator or designee.d. Notify the attending physician, resident's family/legal representative, and Medical Director.e. Monitor and document the resident's condition, including response to medical treatment or nursing interventions.f. Document actions taken in the medical record.The Administrator or designee will:a. Notify the appropriate agencies immediately: as soon as possible, but no later than 24 hours after discovery of the incident. In the case of serious bodily injury, no later than 2 hours after discovery or forming the suspicion. 056162 Page 2 of 2