Other·March 27, 2019

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 the investigation of one Facility Reported Incident. Facility Reported Incident number CA00608608 Representing the California Department of Public Health: Surveyor 39189 The inspection was limited to the specific Facility Reported Incident investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for Facility Reported Incident CA00608608.

F600 SS=D Free from Abuse and Neglect CFR(s): 483.12(a)(1)

F600 03/07/2019 §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: 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: 2BRC11 Facility ID: CA240000010 If continuation sheet 1 of 4 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 02/13/2019 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 Based on observation, interview, and record review, the facility failed to ensure a resident was free from physical abuse, when one of the three sampled residents (Resident A) was tied with a bed sheet from his waist down to the ankle by a staff member with no medical indication. This failure resulted in preventing the resident to move freely which could negatively impact Resident A's psychosocial, and mental wellbeing. Findings: On October 31, 2018, at 9:30 a.m., an unannounced visit was made to the facility to investigate a facility reported incident related to physical abuse. Resident A's record was reviewed. Resident A was re-admitted to the facility on July 25, 2018, with diagnoses which included severe sepsis (body response to infection) and dementia (memory loss). Resident A's history and physical (H&P) indicated, "...does not have the capacity to understand and make decisions." The document titled, "RESIDENT CARE PLAN", dated July 26, 2018, indicated, "...Exposing self in public area by removing adult pad/brief...always approach Resident calmly and Unhurriedly, speak in a clam (sic) voice...keep comfortable as possible, provide privacy ...check residents for needs..." The document titled, "Resident Care Plan Bowel and Bladder" dated October 19, 2018, indicated, "...Episodes of pulling/Removing Adult pad...Interventions...Adult pads when up in w/c (wheelchair) & Remove when in bed if needed..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2BRC11 Facility ID: CA240000010 If continuation sheet 2 of 4 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 02/13/2019 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 A's Interdisciplinary Team (IDT) Conference Record, dated August 14, 2018, indicated, "...Res. (resident) plays with his feces and in need of a lot of redirection. Res to continue to be encourage and plan of care (sic)." On October 31, 2018, at 9:35 a.m., Resident A was observed sitting in bed. Resident A did not have any clothes on and a bed sheet was covering his abdomen and lower extremities. On October 31, 2018, at 11:11 a.m., the Director of Nursing (DON) was interviewed. The DON stated Resident A was tied with a bed sheet by a Certified Nursing Assistant (CNA 1), on October 19, 2018. The DON described how Resident A was tied, "like a burrito" starting from his waist down to the ankles like a "tamale" wrap at the end. She stated the CNA (CNA 1) was preventing Resident A from taking off his brief. On October 31, 2018, at 2:59 p.m., the Director of Staff Development (DSD) was interviewed. The DSD stated the incident happened on October 19, 2018, after lunch, when Resident A's family member (FM) reported to the DSD that the resident (Resident A) was wrapped in a sheet. The DSD stated she attended to Resident A and had to call another CNA (CNA 2) to help her (DSD) untie the sheet from Resident A. The DSD further stated, it was hard to untie the sheet. On October 31, 2018, at 3:32 p.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated Resident A was alert with confusion and would sometimes take off all of his clothes. LVN 1 stated the resident (Resident A) would rip off his brief, and the staff had to cover him with a blanket. LVN 1 stated it was not appropriate to tie the resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2BRC11 Facility ID: CA240000010 If continuation sheet 3 of 4 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 02/13/2019 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 in bed sheets to prevent him from taking off his brief. LVN 1 confirmed it was a type of abuse. On October 31, 2018, at 3:52 p.m., the Administrator (ADM) was interviewed. The ADM confirmed the incident with Resident A, being tied with bed sheets, had occurred. The ADM stated the action was inappropriate. On November 2, 2018, at 11:51 a.m., CNA 2 was interviewed. CNA 2 stated she went to Resident A's room on October 19, 2018, and found Resident A wrapped in a sheet like a "rope". CNA 2 stated Resident A's FM helped her (CNA 2) untie the sheet from Resident A. CNA 2 further stated "It is not ok to tie the patient like that, it is not right." The facility policy and procedure titled, "Abuse - Prevention, Screening, & Training Program," revised July 2018, was reviewed. The policy and procedure indicated, "Purpose: To address the health, safety, welfare, dignity, and respect of residents by preventing abuse, neglect...and mistreatment including freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat medical symptoms. Policy: The Facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment and develops Facility policies, procedures, training programs, and screening and prevention systems to promote an environment free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment... Abuse is defined as the willful, deliberate infliction of injury, unreasonable confinement, involuntary seclusion, physical or chemical restraint not required to treat symptoms and/or imposed for the purposes of discipline or convenience..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2BRC11 Facility ID: CA240000010 If continuation sheet 4 of 4