Other·May 9, 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: CA00597680. Representing the California Department of Public Health: Surveyor 22921, HFEN The inspection was limited to the specific facility reported incident investigated and does not represent the findings of a full inspection of the facility. Two deficiencies were issued for facility reported incident number CA00597680.

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 05/01/2019 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)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 ensure the environment remained free of accident hazards 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: JQKU11 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 04/15/2019 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 for one resident (Resident A), when the facility failed to implement and document an ongoing environmental and person-centered assessment process to proactively find and mitigate (reduce) safety risks, related to the physical environment, that could be used to attempt suicide and self-injurious behavior. This failure resulted in the death of Resident A when she used a cubicle privacy curtain (curtain used in a multi-patient room to provide privacy) suspended from the ceiling and tied around her neck to hang herself. Findings: An unannounced visit was made to the facility on August 1, 2018, at 8:35 a.m., to investigate a facility reported incident that occurred on July 31, 2018. The facility reported Resident A died by suicide by tying a cubicle privacy curtain around her neck and hanging. The facility reported Patient A was sent to the general acute care hospital and was pronounced dead in the emergency room. An observation of Resident A's room and concurrent interview with the Director of Nursing (DON) were conducted on August 1, 2018, at 9:08 a.m. Resident A was assigned to a two-bed room. The cubicle privacy curtain for the bed assigned to Resident A was missing from the room. The DON stated the County Coroner had already removed the cubicle privacy curtain from around Resident A's bed. The track on the ceiling which held the curtain was observed to be intact. The DON stated Resident A may have gathered the curtain, wrapped it around her neck, got on her knees and leaned forward. The DON stated Resident A weighed 286 lbs (pounds) and "the curtain or rail did not fall." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JQKU11 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 04/15/2019 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 The record for Resident A was reviewed on August 1, 2018. Resident A was admitted to the facility on July 25, 2018, with a diagnosis of schizophrenia (a mental disorder). The "...Psychological Evaluation and Assessment," dated July 28, 2018, indicated Resident A had a history of trying to commit suicide when she was 19 years old. A review of the facility document titled, "INTERDISCIPLINARY TEAM NOTES," dated July 31, 2018, at 2 p.m., indicated, " ...CNA (Certified Nursing Assistant) reported that at approximately 11:54 AM she was making her safety check rounds, when she opened the door to (Resident A's room number) (Resident A's name) was in kneeling position with the privacy curtain tied around her neck. Code blue (code for emergencies) was immediately called...A call was placed to 911 (phone number used to activate emergency services) ..." The document titled, "EMERGENCY PROVIDER REPORT," from the acute hospital, dated July 31, 2018, at 12:55 p.m., indicated, " ...Patient arrived ... status post hanging ...Patient expired (died) secondary to cardiopulmonary arrest (absence of heartbeat or breathing) following traumatic hanging ..." An unannounced visit was made to the facility on September 15, 2018. The "Facility Assessment 2018," dated as approved by the facility QAA (Quality Assessment and Assurance) Committee on October 16, 2017, was reviewed. The assessment did not specify the environment would be assessed to identify hazards and risks for residents that could be used to attempt suicide and self-injurious behavior. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JQKU11 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 04/15/2019 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 An interview was conducted with the Administrator on September 15, 2018, at 1:30 p.m. The Administrator was asked if there was any documentation indicating what the facility reviewed in terms of the physical environment to mitigate the risk of any suicide attempts the Administrator stated, "Other than general discussion, we didn't document." The Administrator was not able to provide documented evidence a thorough environmental assessment to mitigate the risk of self-injurious behavior by residents was conducted by the facility. During a telephone interview conducted with the Administrator on January 9, 2019, at 3 p.m., the Administrator was asked if the facility conducted any type of regular routine assessment of the environment in order to be proactive in reducing the risk of suicide. The Administrator stated they conducted rounds every day and facility wide room checks for contraband (items not allowed in the facility) on a monthly basis, but that they did not have an exact form that was specific for routine assessments of suicide prevention. The Administrator was asked if the cubicle privacy curtains were considered a potential risk prior to the July 2018 suicide of patient A. The Administrator stated the cubicle privacy curtains never came across their minds because they always fell down. The facility was not able to provide a policy and procedure for environmental risks assessment to mitigate self-injurious behaviors by residents. The document titled, " ...Coroner Investigation ...Coroner Supplemental," from the County FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JQKU11 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 04/15/2019 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 Coroner Division, dated February 28, 2019, was reviewed on March 12, 2019. The document indicated Patient A's cause of death was determined to be "Asphyxia (condition when the body is deprived of oxygen) by Hanging," and the manner of death was classified as "Suicide ..."

F838 SS=D Facility Assessment CFR(s): 483.70(e)(1)-(3)

F838 05/01/2019 §483.70(e) Facility assessment. The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. The facility assessment must address or include: §483.70(e)(1) The facility's resident population, including, but not limited to, (i) Both the number of residents and the facility's resident capacity; (ii) The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population; (iii) The staff competencies that are necessary to provide the level and types of care needed for the resident population; (iv) The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population; and (v) Any ethnic, cultural, or religious factors that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JQKU11 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 04/15/2019 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 may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services. §483.70(e)(2) The facility's resources, including but not limited to, (i) All buildings and/or other physical structures and vehicles; (ii) Equipment (medical and non- medical); (iii) Services provided, such as physical therapy, pharmacy, and specific rehabilitation therapies; (iv) All personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care; (v) Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and (vi) Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations. §483.70(e)(3) A facility-based and communitybased risk assessment, utilizing an all-hazards approach. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to create a facility-wide assessment specific to the needs of the facility population, when the facility assessment did not include an evaluation of the physical environment to identify hazards and risks for residents that could be used to attempt suicide and self-injurious behavior. This resulted in the facility's failure to identify FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JQKU11 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 04/15/2019 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 what resources were necessary to care for the residents in a safe and secure manner on a day-to-day basis when the cubicle privacy curtains (curtain used in a multi-patient room to provide privacy) were not assessed as a possible way to commit suicide by hanging. Furthermore, Resident A used the privacy curtain in her room to commit suicide by hanging. Findings: An unannounced visit was made to the facility on August 1, 2018, at 8:35 a.m., to investigate a facility reported incident that occurred on July 31, 2018. The facility reported Resident A died by suicide by tying a cubicle privacy curtain around her neck and hanging. An observation of Resident A's room, and concurrent interview with the Director of Nursing (DON) was conducted on July 31, 2018, at 9:08 a.m. Resident A was assigned to a two-bed room. The DON stated Resident A may have gathered the curtain, wrapped it around her neck, got on her knees and leaned forward. The DON stated Resident A weighed 286 lbs (pounds) and "the curtain or rail did not fall." An interview was conducted with the Administrator on September 15, 2019, at 1:30 p.m. When asked if there was any documentation indicating what the facility reviewed in terms of the physical environment to mitigate the risk of any suicide attempts the Administrator stated, "Other than general discussion, we didn't document." The Administrator was not able to provide documented evidence a thorough environmental assessment to mitigate the risk of self-injurious behavior by residents was conducted by the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JQKU11 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 04/15/2019 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 During a telephone interview conducted with the Administrator on January 9, 2019, at 3 p.m., the Administrator was asked if the facility conducted any type of regular routine assessment of the environment in order to be proactive in reducing the risk of suicide. The Administrator stated they conducted rounds every day and facility wide room checks for contraband (items not allowed in the facility) on a monthly basis, but that they did not have an exact form that was specific for routine assessments of suicide prevention. An unannounced visit was made to the facility on September 15, 2018. The "Facility Assessment 2018," dated as approved by the facility QAA (Quality Assessment and Assurance) Committee on October 16, 2017, was reviewed. The assessment did not specify the environment would be assessed to identify hazards and risks to residents that could be used to attempt suicide and self-injurious behavior. An unannounced visit was made to the facility on April 9, 2019. During an interview with the Director of Nursing (DON) on April 9, 2019, at 9:05 a.m., the DON stated the facility assessment was in effect July 31, 2018, at the time of the incident. The DON reviewed the facility assessment and confirmed the facility assessment did not include an assessment of the environment to identify risks and hazards to residents that could be used to attempt suicide and self-injurious behavior. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JQKU11 Facility ID: CA240000021 If continuation sheet 8 of 8