F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
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 an environment free of accident
hazards and to ensure resident receives adequate supervision and assistance devices, for three of three
residents reviewed for accidents (Residents 34, 85 and 24) when:1.Resident 34 was found to have
cigarettes and a lighter at bedside. This failure had the potential to place Resident 34 and other residents at
risk for harm and injuries.2.Resident 85 did not receive adequate supervision and effective fall prevention
interventions.This failure resulted in Resident 85 sustaining a fall with facial injuries requiring hospital
transfer. 3.Resident 24, assistance device (call light) was not within reach.This failure had the potential to
result in the resident being unable to request for assistance, placing her at risk for injury.Findings:
1.On February 9, 2026, at 9:44 a.m., a concurrent observation and interview with Resident 34 was
conducted in her room. Resident 34 stated she smokes cigarettes with supervision and was observed to
have cigarettes and a lighter at bedside.
A review of Resident 34's admission Record dated February 12, 2026, indicated an admission date of
December 23, 2025, with diagnoses which included metabolic encephalopathy (brain dysfunction).
A review of Resident 34's History and Physical dated December 24, 2025, indicated resident had the
capacity to understand and make decisions.
A review of Resident 34's Smoking assessment dated [DATE], indicated, .Safety factors.burns skin,
clothing, furniture or other.drops ashes on self.Recommendation.smoke with supervision.
On February 11, 2026, at 11:13 a.m., a concurrent interview and record review with Licensed Vocational
Nurse (LVN) 15 was conducted. LVN 15 stated residents are not allowed to keep cigarettes and lighters at
bedside. LVN 15 stated all staff are responsible for ensuring smoking paraphernalia is not kept at bedside
without staff knowledge. LVN 15 stated is a resident does not want to surrender smoking paraphernalia to
staff, an Interdisciplinary Team (IDT) meeting should be completed and should be care planned. LVN 15
stated there was no documented evidence that an IDT meeting was conducted, or care plan was initiated
related to Resident 34 keeping her smoking paraphernalia at bedside. LVN 15 stated she was not aware
Resident 34 had cigarettes and a lighter at bedside and Resident 34 should not have had these items at
bedside, since an IDT was not done and it was not included in the care plan. LVN 15 stated it was important
to follow the facility's protocol for managing smoking paraphernalia to prevent resident harm and risks for
safety and fire.
On February 12, 2026, at 10:47 a.m., an interview with the Assistant Director of Nursing (ADON) was
(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 3
Event ID:
056162
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
056162
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/13/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Extended Care Hospital of Riverside
8171 Magnolia Avenue
Riverside, CA 92504
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 - Minimal harm
or potential for actual harm
Residents Affected - Some
conducted. The ADON stated if a resident is alert and oriented times four and requested to have their
smoking paraphernalia at bedside, staff should have conducted an IDT meeting, informed the physician,
initiated a care plan, and provided education on safety. The ADON stated there was no documented
evidence that an IDT meeting was conducted, the physician was notified, and a care plan initiated. The
ADON stated Resident 34 should not have had cigarettes and a lighter at bedside. The ADON stated this
was important to ensure safety for all residents.
A review of the facility's policy and procedures titled, Resident Smoking, dated October 20, 2025, indicated,
.provide a safe and healthy environment for residents, visitors, and employees, including safety as related
to smoking.Smoking materials.maintained by designated staff.
2. A review of Resident 85's admission Record dated February 17, 2026, indicated the resident was
admitted to the facility on [DATE], with diagnoses including abnormalities of gait and mobility.
A review of Resident 85's History and Physical dated October 24, 2025, indicated the resident did not have
the capacity to understand and make decisions.
A review of Resident 85's Fall Risk Assessment, dated October 23, 2025, indicated Resident 85 was at risk
for falls.
A review of Resident 85's Minimum Data Set (an assessment tool) dated January 10, 2026, indicated
Resident 85 required supervision or touching assistance for chair/bed to chair transfer.
A review of Resident 85's SBAR (Situation, Background, Appearance, Review and Notify) Communication
Form, dated January 26, 2026, indicated .At approximately 11:15, resident had an unwitnessed fall and
was found laying (sic)on the floor in a prone position .Verbal and able to follow commands. No changes to
LOC (level of consciousness) .send to ER .
A review of Resident 85's Care plan indicated there was no revisions of the care plan addressing the
resident's behavior of attempting to transfer independently without supervision after becoming aware of the
resident's behavior prior to the fall.
On February 11, 2026, at 12:05 p.m., an interview was conducted with CNA 3, CNA 3 stated Resident 85
fell face forward while attempting to transfer from her wheelchair to the bed and sustained facial injuries.
CNA 3 stated Resident 85 could perform transfers with supervision. CNA 3 stated Resident 85 was a fall
risk, and it was not safe to be left unattended in the wheelchair. CNA 3 stated she previously observed
Resident 85 transfer herself from the wheelchair to the toilet without supervision and did not report to the
licensed nurse and she should have.
On February 11, 2026, at 12:15 p.m., an interview was conducted with CNA 4. CNA 4 stated on January
26, 2026, she heard a noise coming from Resident 85's room and found the resident on the floor. CNA 4
stated the resident had black eyes, swelling to the nose, knot on the head, and nose was bleeding. CNA 4
stated the resident was sent to the hospital. CNA 4 stated Resident 85 had a history of attempting to get up
on without staff assistance and that staff were aware of this behavior.
On February 11, 2026, at 2:48 p.m., an interview was conducted with CNA 5. CNA 5 stated she was aware
Resident 85 would attempt to stand from the wheelchair independently. CNA 5 stated, on January 26, 2026,
she was covering for Resident 85's assigned CNA. CNA 5 stated she last saw the resident in the dining
room and did not know when the resident returned to her room as she was assisting another
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056162
If continuation sheet
Page 2 of 3
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
056162
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/13/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Extended Care Hospital of Riverside
8171 Magnolia Avenue
Riverside, CA 92504
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
resident.
Level of Harm - Minimal harm
or potential for actual harm
On February 12, 2026, at 10:47 a.m., an interview with the Assistant Director of Nursing (ADON) was
conducted. ADON stated CNAs were expected to report unsupervised transfer attempts to the licensed
nurse so that a fall risk assessment could be completed and the behavior care planned. The ADON stated
Resident 85's behavior of attempting to transfer independently should have been reported and addressed
through updated care planning. The ADON stated Resident 85 should not have been left unattended in her
wheelchair and her attempts to get up without supervision should have been reported to the nurse. The
ADON stated this was important to prevent accidents, harm, and falls.
Residents Affected - Some
A review of the facility's policy and procedure titled, Fall Prevention Program, dated December 28, 2023,
indicated, Each resident .will receive care and services in accordance with their individualized level of risk
to minimize the likelihood of falls . provide additional interventions as directed by the resident's assessment
.
A review of the facility's policy and procedure titled, Fall Risk assessment dated [DATE], indicated, .
provides supervision . to each resident to prevent avoidable accidents . risk assessment will be completed
by the nurse . when a significant change is identified . risk assessment will contain .individual risks,
including the need for supervision .fall care plan will include interventions, including adequate supervision .
to reduce the risk of an accident .
3. On February 10, 2026, at 8:35 a.m., Resident 24 was heard yelling from inside her room. Upon entering,
Resident 24 was observed in bed with her call light hanging to the side of the bed and not within reach.
Resident 24 stated she wanted her bedside table moved. Resident 24 stated she was unable to locate her
call light.
A review of Resident 24's admission Record, indicated Resident 24 was admitted to the facility on [DATE],
with diagnoses which included frequent falls.
A review of Resident 24's History and Physical, dated January 20, 2026, indicated Resident 24 does not
have the capacity to understand and make decisions.
A review of Resident 24's Care Plan dated January 28, 2026, indicated .The resident is at risk for falls r/t
(related to) Gait/balance problems, Unaware of safety needs, History of Fall .Place resident's call light is
within reach.The resident needs prompt response to all requests for assistance .
On February 10, 2026, at 8:37 a.m., during a concurrent observation and interview with Licensed
Vocational (LVN) 1, LVN 1 stated Resident 24's call light was not within reach, and it should have been. LVN
1 stated if the call light was not within her reach, the resident would be unable to request assistance,
including during an emergency.
A review of facility Policy and Procedure titled Call Lights: Accessibility and timely Response, dated
December 19, 2022, indicated .Staff will ensure the call light is within reach of resident and secured as
needed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056162
If continuation sheet
Page 3 of 3
