Other·September 1, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated standard survey to investigate an entity reported incident. Entity reported incident: CA00486536 Representing the California Department of Public Health: Surveyor: 23046, HFEN The inspection was limited to the specific entity reported incident investigated and does not represent the findings of a full inspection of the facility. Two deficiencies were written as a result of entity reported incident CA00486536.

F323 SS=G FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(h)

F323 08/18/2017 The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide a safe LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVFO11 Facility ID: CA240000010 If continuation sheet 1 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055042 (X3) DATE SURVEY COMPLETED 08/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALTA VISTA HEALTHCARE & WELLNESS CENTRE 9020 Garfield St Riverside, CA 92503 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE environment to prevent injuries and accidents for one sampled resident (Resident 1) while the resident was being transported to her dialysis (process of removing waste from the blood by a machine) clinic using the facility's transport bus. The facility failed to properly secure Resident 1's wheelchair in the bus during the transport which resulted in the resident and wheelchair tilting backwards and causing Resident 1 to hit her head on the back wall of the bus. Resident 1 complained of pain to the back of the head and upper back area. Resident 1 was later transported to the hospital emergency room (ER) for further evaluation and treatment. Findings: On May 17, 2016, at 9:40 a.m., an unannounced visit was made to the facility. Review of Resident 1's medical record indicated she was admitted to the facility on April 28, 2016, and had diagnoses that included status post above the knee amputation (AKA), end stage renal disease (ESRD - inability of the kidneys to remove waste from the blood and make urine), weakness, and legally blind in the left eye. Resident 1 received dialysis treatment three times a week at a dialysis clinic away from the facility. A written investigative summary and time line of the events, dated May 2, 2016, was provided by the facility Assistant Administrator (AA) and indicated the following: "...8:56 am while driving to the Dialysis (clinic), (Resident 1's name) strap became loose and slipped through the tightening clasp causing the chair to move forward and to subsequently tilt back when accelerating. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVFO11 Facility ID: CA240000010 If continuation sheet 2 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055042 (X3) DATE SURVEY COMPLETED 08/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALTA VISTA HEALTHCARE & WELLNESS CENTRE 9020 Garfield St Riverside, CA 92503 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 8:57 am (name of van driver) pulled the bus over to the side of the road and repositioned, re-strapped, and double checked all fittings and buckles. 8:57 am (name of van driver) asked if she (Resident 1) was ok, she stated "my back hurts a little but I'm ok." The facility's written investigative summary of events further indicated Resident 1 complained of back pain, wanted to go to the emergency room (ER), and was afraid of being transported by the facility bus. On May 17, 2016, at 9:55 a.m., the facility bus driver, who was also the Maintenance Supervisor (MS), was interviewed. He was asked about the incident involving Resident 1 while inside the facility bus being transported to the dialysis clinic on May 2, 2016. The MS stated, "Straps came off loose," referring to the front anchor straps from the floor that went around the bottom frame of the resident's wheelchair when the bus came to a stop at a red light. The MS stated the bus then accelerated forward at the green light. The MS stated Resident 1 was still seated in the wheelchair when the wheelchair was tilted backward toward the back wall of the bus. The MS stated the straps that came off were old, defective, and thrown away after the accident, and new anchor straps had been ordered. The MS could not confirm if the defective straps were the reason they came off, or if the MS did not properly secure them. When the MS was asked about his job responsibilities at the facility, the MS stated he was hired two months ago and his main job responsibility was as Maintenance and Housekeeping Supervisor. The MS stated he FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVFO11 Facility ID: CA240000010 If continuation sheet 3 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055042 (X3) DATE SURVEY COMPLETED 08/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALTA VISTA HEALTHCARE & WELLNESS CENTRE 9020 Garfield St Riverside, CA 92503 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE was to make sure life and safety equipment used by residents in the facility were in good working condition. The MS further stated he was given additional work responsibility to take over as a bus driver, transporting residents to their scheduled appointments (such as at dialysis clinics) when the main bus driver was not available. The MS was further asked if he was given orientation or training regarding resident safety when transporting residents, prior to assuming the responsibility as facility bus driver. The MS stated, "No training, no orientation." On May 17, 2016, at 11:35 a.m., an interview with the Administrator and the Assistant Administrator (AA) was conducted. The Administrator and AA were asked if, prior to the accident involving Resident 1, the facility bus drivers including the MS had been provided with safety training and orientation for transporting residents on the facility bus. The Administrator acknowledged the designated facility bus drivers including the MS did not receive safety training and/or orientation on safe transport of residents until after the accident occurred with Resident 1. The Administrator could not confirm if the wheelchair straps came off because they were defective, or because the MS did not properly secure them. The Administrator was asked if the facility had a safety policy and procedure for transporting residents in the facility bus. The Administrator was not able to provide the requested policy. The Administrator, instead, provided a written, undated document titled, "Van Driver/Transporter Job Description." The job description indicated the driver's principal responsibilities which included: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVFO11 Facility ID: CA240000010 If continuation sheet 4 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055042 (X3) DATE SURVEY COMPLETED 08/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALTA VISTA HEALTHCARE & WELLNESS CENTRE 9020 Garfield St Riverside, CA 92503 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE "...Provides transportation of residents to and from physician appointments in a timely manner... Maintains a high level of safety following safety policies and procedures while in Center and transporting residents. Maintains van (bus) in good working condition..." On June 20, 2016, at 9:25 a.m., Resident 1 was observed at the dialysis clinic prior to the start of her dialysis treatment. Resident 1 was seated in a wheelchair and had an AKA of the left leg. Resident 1 was awake, alert, and able to communicate verbally. In a concurrent interview with Resident 1, on June 20, 2016, at 9:25 a.m., she was asked about her health condition, and the incident she had inside the facility's transport bus on May 2, 2016. Resident 1 stated she was sitting in her wheelchair which was anchored at the back end of the bus. The resident stated she was so scared when the straps at the bottom of her wheelchair came off, and as the bus accelerated forward she was abruptly pushed backward toward the wall of the bus. The resident explained that the backward force tipped her wheelchair backwards in a tilted position, with her legs thrown upward and her head in a downward direction as the wheelchair traveled backward toward the back wall of the bus. Resident 1 stated, "The driver (the facility's Maintenance Supervisor) didn't even notice I fell backward. I have to keep yelling at him to stop the van (facility bus)." Resident 1 stated she hit the back of her head and upper back on the back wall of the bus and sustained a small bump on the back of her head. The resident further stated she had pain on her head and upper back area after the incident. On June 20, 2016, at 9:35 a.m., the dialysis Registered Nurse (RN 1) was interviewed regarding Resident 1's health condition before, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVFO11 Facility ID: CA240000010 If continuation sheet 5 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055042 (X3) DATE SURVEY COMPLETED 08/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALTA VISTA HEALTHCARE & WELLNESS CENTRE 9020 Garfield St Riverside, CA 92503 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE during, and after her dialysis treatment on May 2, 2016. RN 1 stated Resident 1 was alert, oriented, and complained of upper back pain. The resident's physician at the dialysis clinic was notified of the incident with orders to send Resident 1 to the ER for further evaluation and treatment. RN 1 stated Resident 1 requested and wanted to complete her dialysis treatment at the clinic prior to being transferred to the ER. Resident 1's dialysis treatment record dated May 2, 2016, indicated, "...complained of back pain... 5/10 (moderate pain on pain scale on 1/10), ...symptomatic hypotension (abnormally low blood pressure): lightheadedness, cramping. ...Sent to ER (acute hospital's name) for evaluation and possible CT (CAT Scan/xray) of the head. Seen by (physician's name)." A review of the ER physician and nurse's notes dated May 2, 2016, indicated Resident 1 complained of "headache, dizziness", and moderate pain on the "head and neck." The diagnostic considerations (potential injury result) Resident 1 was being assessed for included closed head injury, fractures (broken bone) and hematoma (bruise). Resident 1 further received laboratory tests including CT Scan of the head and spine, and was admitted to the hospital as in-patient for further observation and treatment. The CT Scan results indicated, "No apparent fracture (of the head and spine) or dislocation..."

F493 SS=E GOVERNING BODY-FACILITY POLICIES/APPOINT ADMN CFR(s): 483.75(d)(1)-(2)

F493 08/25/2017 The facility must have a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility; and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVFO11 Facility ID: CA240000010 If continuation sheet 6 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055042 (X3) DATE SURVEY COMPLETED 08/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALTA VISTA HEALTHCARE & WELLNESS CENTRE 9020 Garfield St Riverside, CA 92503 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the governing body appoints the administrator who is licensed by the State where licensing is required; and responsible for the management of the facility This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility's governing body failed to establish and implement a safety policy and procedure, and provide staff education and training, for transporting residents to and from their scheduled appointments outside the facility in the facility's transport bus (van). This facility failure resulted in two facility bus drivers not being provided with proper safety training and orientation while transporting residents to their appointments, had the potential to jeopardize the health and safety of multiple residents during their transport to and from appointments, and resulted in one resident (Resident 1) having an incident in the bus causing a head injury, pain and being transported to the emergency room (ER). Findings: On May 17, 2016, at 9:40 a.m., an unannounced visit was made to the facility. Review of Resident 1's medical record indicated she was admitted to the facility on April 28, 2016, and had diagnoses that included status post above the knee amputation (AKA), end stage renal disease (ESRD - inability of the kidneys to remove waste from the blood and make urine), weakness, and legally blind in the left eye. Resident 1 received dialysis treatment three times a week at a dialysis clinic away from the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVFO11 Facility ID: CA240000010 If continuation sheet 7 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055042 (X3) DATE SURVEY COMPLETED 08/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALTA VISTA HEALTHCARE & WELLNESS CENTRE 9020 Garfield St Riverside, CA 92503 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A written investigative summary and time line of the events which occurred on May 2, 2016, was provided by the facility Assistant Administrator (AA) and indicated the following: "...8:56 am while driving to the Dialysis (clinic), (Resident 1's name) strap became loose and slipped through the tightening clasp causing the chair to move forward and to subsequently tilt back when accelerating. 8:57 am (name of van driver) pulled the bus over to the side of the road and repositioned, re-strapped, and double checked all fittings and buckles. 8:57 am (name of van driver) asked if she (Resident 1) was ok, she stated "my back hurts a little but I'm ok." The written investigative summary of events further indicated Resident 1 complained of back pain, wanted to go to the emergency room (ER), and was afraid of being transported by the facility bus. On May 17, 2016, at 9:55 a.m., the facility bus driver, who was also the Maintenance Supervisor (MS), was interviewed and asked about the incident involving Resident 1 inside the facility bus while being transported to the dialysis clinic on May 2, 2016. The MS stated, "Straps came off loose," referring to the front anchor straps from the floor that went around the bottom frame of the resident's wheelchair when the bus came to a stop at a red light. The MS stated the bus then accelerated forward at the green light. The MS stated Resident 1 was still seated in the wheelchair when the wheelchair was tilted backward toward the back wall of the bus. The MS stated the straps that came off were old, defective, thrown away after the accident, and new anchor straps had FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVFO11 Facility ID: CA240000010 If continuation sheet 8 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055042 (X3) DATE SURVEY COMPLETED 08/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALTA VISTA HEALTHCARE & WELLNESS CENTRE 9020 Garfield St Riverside, CA 92503 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE been ordered. The MS could not confirm if the incident happened due to the straps being defective, or due to the MS not ensuring the straps were properly secured. When the MS was asked about his job responsibilities at the facility, the MS stated he was hired two months ago and his main job responsibility was as Maintenance and Housekeeping Supervisor. The MS stated he was to make sure life and safety equipment used by residents in the facility were in good working condition. The MS further stated he was given additional work responsibility to take over as a bus driver, transporting residents to their scheduled appointments (such as at dialysis clinics) when the main bus driver was not available. The MS was further asked if he was given orientation or training regarding resident safety when transporting residents, prior to assuming the responsibility as facility bus driver. The MS stated, "No training, no orientation." On May 17, 2016, at 11:35 a.m., a concurrent interview with the Administrator and the Assistant Administrator (AA) was conducted. The Administrator and AA were asked if, prior to the incident involving Resident 1, the facility bus drivers including the MS had been provided with safety training and orientation for transporting residents on the facility bus. The Administrator acknowledged the designated facility bus drivers including the MS, did not receive safety training and/or orientation on safe transport of residents until after the incident occurred with Resident 1. When asked further if the facility had a safety policy and procedure for transporting residents in the facility bus, the Administrator was not able to provide the requested policy. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVFO11 Facility ID: CA240000010 If continuation sheet 9 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055042 (X3) DATE SURVEY COMPLETED 08/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALTA VISTA HEALTHCARE & WELLNESS CENTRE 9020 Garfield St Riverside, CA 92503 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Administrator, instead, provided a written, undated document titled, "Van Driver/Transporter Job Description." The job description indicated the driver's principal responsibilities which included: "...Provides transportation of residents to and from physician appointments in a timely manner... Maintains a high level of safety following safety policies and procedures while in Center and transporting residents. Maintains van (bus) in good working condition..." On June 20, 2016, at 9:25 a.m., Resident 1 was observed at the dialysis clinic prior to the start of her dialysis treatment. Resident 1 was seated in a wheelchair and had an AKA of the left leg. Resident 1 was awake, alert, and able to communicate verbally. In a concurrent interview with Resident 1, on June 20, 2016, at 9:25 a.m., she was asked about her health condition, and the incident she had inside the facility's transport bus on May 2, 2016. Resident 1 stated she was sitting in her wheelchair which was anchored at the back end of the bus. The resident stated she was so scared when the straps at the bottom of her wheelchair came off, and as the bus accelerated forward she was abruptly pushed backward toward the wall of the bus. The resident explained that the backward force tipped her wheelchair backwards in a tilted position, with her legs thrown upward and her head in a downward direction as the wheelchair traveled backward toward the back wall of the bus. Resident 1 stated, "The driver (the facility's Maintenance Supervisor) didn't even notice I fell backward. I have to keep yelling at him to stop the van (facility bus)." Resident 1 stated she hit the back of her head and upper back on the back wall of the bus and sustained a small bump on the back of her head. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVFO11 Facility ID: CA240000010 If continuation sheet 10 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055042 (X3) DATE SURVEY COMPLETED 08/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALTA VISTA HEALTHCARE & WELLNESS CENTRE 9020 Garfield St Riverside, CA 92503 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident further stated she had pain on her head and upper back area after the incident. On June 20, 2016, at 9:35 a.m., the dialysis Registered Nurse (RN 1) was interviewed regarding Resident 1's health condition before, during, and after her dialysis treatment on May 2, 2016. RN 1 stated Resident 1 was alert, oriented, and complained of upper back pain. The physician was notified of the incident with orders to send Resident 1 to the ER for further evaluation and treatment. RN 1 further stated Resident 1 requested and wanted to complete her dialysis treatment at the clinic prior to being transferred to the ER. Resident 1's dialysis treatment record dated May 2, 2016, indicated, "...complained of back pain... 5/10 (moderate pain on pain scale on 1/10), ...symptomatic hypotension (abnormally low blood pressure): lightheadedness, cramping. ...Sent to ER (acute hospital's name) for evaluation and possible CT (x-ray) of the head. Seen by (physician's name)." A review of the ER physician and nurse's notes dated May 2, 2016, indicated Resident 1 complained of "headache, dizziness", and moderate pain on the "head and neck." The diagnostic considerations (potential injury result) included, "Closed head injury, Fracture (broken bone) and Hematoma (bruise)." Resident 1 further received laboratory tests including CT of the head and spine, and was admitted to the hospital as in-patient for further observation and treatment. CT results indicated, "No apparent fracture (of the head and spine) or dislocation..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVFO11 Facility ID: CA240000010 If continuation sheet 11 of 11