Other·September 7, 2017

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 for the investigation of one entity reported incident. Entity reported incident number CA 00534557. Representing the California Department of Public Health: Surveyor 36239 The inspection was limited to the specific entity reported incident investigated and does not represent the findings of a full inspection of the facility. A deficiency was issued for entity reported incident number CA 00534557.

F226 SS=D DEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES CFR(s): 483.12(b)(1)-(3), 483.95(c)(1)-(3)

F226 08/28/2017 483.12 (b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations, and (3) Include training as required at paragraph §483.95, 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: IE9J11 Facility ID: CA240000021 If continuation sheet 1 of 8 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: _______________ 05A263 (X3) DATE SURVEY COMPLETED 07/13/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE BEHAVIORAL HEALTHCARE CENTER 4580 Palm Ave Riverside, CA 92501 (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 483.95 (c) Abuse, neglect, and exploitation. In addition to the freedom from abuse, neglect, and exploitation requirements in § 483.12, facilities must also provide training to their staff that at a minimum educates staff on(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at § 483.12. (c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property (c)(3) Dementia management and resident abuse prevention. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to implement the facility policy and procedure for abuse after Resident A reported to staff that Resident B raped her. The facility failed to: 1. Provide follow-up care for the Resident A after the alleged rape; and 2. Ensure Resident B was placed on one to one Behavior Precaution (BP) monitoring (one staff member with the resident at all times to ensure the safety of other residents), as outlined in the policy and procedure, in order to ensure Resident A's safety. These facility failures increased the potential for serious psychological and physical harm or injury for residents in the facility. Findings: On May 10, 2017, a facility policy and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IE9J11 Facility ID: CA240000021 If continuation sheet 2 of 8 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: _______________ 05A263 (X3) DATE SURVEY COMPLETED 07/13/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE BEHAVIORAL HEALTHCARE CENTER 4580 Palm Ave Riverside, CA 92501 (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 procedure titled, "Reporting Suspected Cases and/or Incidents of Rape," dated August 2012 was reviewed. The policy indicated: "...3. The following action must be taken in cases of suspected / actual rape: ...a. Assess the resident for possible injuries... ...b. Provide medical treatment, as indicated, to prevent further deterioration in the resident's health. Provide the resident with emotional support..." 1. On May 10, 2017, a review of facility documentation dated May 9, 2017, at 1:40 p.m., indicated Resident A went to staff on May 9, 2017, at 8:15 a.m., and reported she had been raped by Resident B the previous evening, May 8, 2017, at approximately 8 p.m. On May 20, 2017, a record review was conducted for Resident A. The resident was admitted to the facility on April 27, 2017, from an acute psychiatric facility with diagnoses including schizoaffective disorder, bipolar Type (chronic mental health condition which can include severe symptoms of hallucinations, delusions, mood disorders, and depression). Resident A's history and physical dated May 2, 2017, was reviewed and indicated the resident had the capacity to understand and make decisions. On May 10, 2017, at 12:15 p.m., during an interview with Resident A, she stated that, on May 8, 2017, at approximately 8 p.m., Resident B came into her room and told her he wanted her to be his girlfriend. Resident A stated that Resident B then took off his pants, climbed on top of her, placed his penis in her vagina, and had sex with her. Resident A stated there were two male residents standing at the doorway FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IE9J11 Facility ID: CA240000021 If continuation sheet 3 of 8 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: _______________ 05A263 (X3) DATE SURVEY COMPLETED 07/13/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE BEHAVIORAL HEALTHCARE CENTER 4580 Palm Ave Riverside, CA 92501 (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 watching, but she was too afraid to say anything. Resident A stated when Resident B was done he got off of her, wiped himself off, got dressed and left the room. Resident A stated she was really scared when Resident B forced her to have sex with him. On May 10, 2017, an observation of Resident A's room was conducted. The room was observed to have two beds, with Resident A's bed located closest to the entry door for the room. A review of the nurses notes from May 9, 2017, at 8:15 a.m., to May 10, 2017, at 12:15 p.m., was conducted. The following was noted: May 9, 2017, 7 a.m.-3 p.m. (day shift): There were no nursing notes for this shift. One program note at 1:40 p.m., indicated the resident reported to staff at 8:15 a.m., that she was raped the previous evening. Resident A stated she did not feel safe at the building. There was no documented nursing assessment after the rape allegation or indication of what type of interventions, if any, were provided for Resident A. May 9, 2017, 3 p.m.-11 p.m. (afternoon shift): A nurses note at 10:15 p.m., indicated the Resident B was on a one to one after she alleged she was raped by a male peer. The resident denied pain related to the alleged rape. There was no documented assessment or indication of what type of interventions beside the one to one, were provided for Resident A. During a review of nursing notes on May 10, 2017, at 12:15 p.m., there were no other nurses notes or documentation of a nursing assessment for Resident A in the 28 hour time frame after Resident A made the allegation of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IE9J11 Facility ID: CA240000021 If continuation sheet 4 of 8 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: _______________ 05A263 (X3) DATE SURVEY COMPLETED 07/13/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE BEHAVIORAL HEALTHCARE CENTER 4580 Palm Ave Riverside, CA 92501 (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 rape against Resident B. On May 10, 2017, at 11:45 a.m., during an interview with the Director of Nursing (DON), she stated the nurses notes and interventions for the alleged rape were documented on the SBAR (Situation Background Assessment Recommendation) form (a form the facility uses to document an incidence). A review of the SBAR form was conducted.The SBAR form did not include documentation indicating the facility completed a physical assessment and/ or assessed the resident's need for emotional support after the alleged rape. In addition, the DON stated the police officer who came to the facility after the alleged rape was reported, stated he did not think the alleged rape ever happened. The DON stated, based on the police officer's opinion, the facility staff agreed that the alleged rape never occurred. The DON stated, if staff thought the alleged rape had actually occurred, they would have done more comprehensive documentation of Resident A's assessments and documented any immediate interventions put into place for Resident A by the psychiatric team. On May 10, 2017, at 12:30 p.m., during a interview with the DON, she stated the facility should not have based their investigation on the police officer's opinion on the allegation of rape. The DON stated the facility should have followed the policy and procedure and completed the documentation and appropriate interventions for Resident A after the resident reported the alleged rape. 2. On May 10, 2017, a facility policy and procedure titled, "Abuse Procedure," dated April 2017, was reviewed. The policy indicated: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IE9J11 Facility ID: CA240000021 If continuation sheet 5 of 8 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: _______________ 05A263 (X3) DATE SURVEY COMPLETED 07/13/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE BEHAVIORAL HEALTHCARE CENTER 4580 Palm Ave Riverside, CA 92501 (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 " Client to Client Abuse Procedure: ...Whenever client to client abuse is alleged, witnessed, reported or suspected to have occurred staff will implement the following steps to assure client safety: ...1. Separate clients immediately. Aggressor to be placed on a 1:1 Behavioral Precautions monitoring.." On May 10, 2017, a record review was completed for Resident B. The resident was admited to the facility on November 22, 2016, from an acute psychiatric facility with diagnoses including Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). A history and physicial dated December 7, 2016, indicated Resident B had the capacity to understand and make decisions. On May 10, 2017, at 11:45 a.m., during an interview with the Director of Nursing (DON), the DON stated Resident B was already on an every 15 (Q-15) minute watch (resident checked on by staff every 15 minutes) for aggressive behaviors when the alleged rape occurred. She stated, since Resident B was already on a Q-15 minute watch, they just continued the Q-15 minute watch after the allegation of rape. On May 10, 2017, the facility documentation log of the May 8, 2017, Q-15 minute monitoring for Resident B during the time of the alleged rape was reviewed. The Q-15 minute monitoring log indicated Resident B was in his room from 7 - 9 p.m., and was asleep from 7:30 - 8 p.m. On May 10, 2017, at 12:15 p.m., during an interview with Resident A, she stated Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IE9J11 Facility ID: CA240000021 If continuation sheet 6 of 8 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: _______________ 05A263 (X3) DATE SURVEY COMPLETED 07/13/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE BEHAVIORAL HEALTHCARE CENTER 4580 Palm Ave Riverside, CA 92501 (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 B came in her room on May 8, 2017, at approximately 8 p.m., and told her he wanted her to be his girlfriend. Resident B then took off his pants and climbed on top of her. Resident A stated Resident B placed his penis in her vagina and had sex with her. In addition, Resident A stated there were two unidentified males in the doorway watching, but she was too scared to say anything. She stated, when Resident B was done, he got off of her, wiped his penis off with a paper towel, got dressed, and walked out of her room. Resident A stated she was really scared when she felt like she was forced to have sex with Resident B. During an interview conducted with Resident B on May 10, 2017, at 1:10 p.m., Resident B stated he was in Resident A's room on May 8, 2017, between 7:30 - 8 p.m., during the time Resident A stated she was raped. Resident B stated they had consensual sex that evening. Resident B stated there were no males in the doorway observing while they had sex. On May 10, 2017, at 1:30 p.m., during an interview conducted with the DON, she reviewed the Q-15 minute documentation for May 8, 2017. The DON confirmed the facility staff had documented Resident B was in his room asleep between 7:30 - 8 p.m., when Resident B stated was in Resident A's room having sex with her. The DON stated the Q-15 minute documentation was not accurate and did not reflect Resident B's location on May 8, 2017, from 7:30- 8 p.m. On May 10, 2017, during a review of the facility's investigation and follow-up of the alleged rape, there was no indication the facility placed Resident B on one to one monitoring Behavioral Precautions (BP), per the facility abuse policy and procedure, immediately after the accusation was reported to staff. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IE9J11 Facility ID: CA240000021 If continuation sheet 7 of 8 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: _______________ 05A263 (X3) DATE SURVEY COMPLETED 07/13/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERSIDE BEHAVIORAL HEALTHCARE CENTER 4580 Palm Ave Riverside, CA 92501 (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 On May 10, 2017, at 6:25 p.m., during an interview with the DON, she stated Resident B should have been placed on a one to one monitoring BP watch, per the facility policy and procedure, immediately after Resident A reported the alleged rape. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IE9J11 Facility ID: CA240000021 If continuation sheet 8 of 8