Other·November 21, 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 an abbreviated standard survey for the investigation of one facility reported incident: Facility reported incident number CA00646249. Representing the California Department of Public Health: Surveyor: 37626, 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. One deficiency was issued for facility reported incident number CA00646249.

F609 SS=D Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4)

F609 10/31/2019 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not 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: KYZ611 Facility ID: CA240000021 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: _______________ 05A263 (X3) DATE SURVEY COMPLETED 09/26/2019 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 result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure an allegation of abuse was reported to the state agency California Department of Health (CDPH) immediately, but not later that two hours, for one of four residents reviewed (Resident 1). This failure had the potential to place all residents in the facility at risk for harm from abuse. Findings: On July 3, 2019, an unannounced visit was conducted at the facility to investigate a facility reported incident. On July 3, 2019, the record of Resident 1 was reviewed. Resident 1 was admitted to the facility on December 18, 2018, with diagnoses which included schizophrenia (a mental disorder). Resident 1's record included a facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KYZ611 Facility ID: CA240000021 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: _______________ 05A263 (X3) DATE SURVEY COMPLETED 09/26/2019 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 document titled, "Progress Notes," dated June 21, 2019. The document indicated, "...At approximately 22:40 (10:40 p.m.), staff overheard arguing coming from client's (sic, Residents 1 and 2) room. When staff entered clients (sic, Residents 1 and 2) room, client was heard saying, "I'm going to close that door and kick your ass if you don't shut up..." There was no documented evidence the alleged verbal abuse was reported to CDPH within two hours of the incident occurring on June 21, 2019, at 10:40 p.m. On July 8, 2019, at 4:37 p.m., a telephone interview and record review was conducted with the Registered Nurse (RN). The RN stated that on June 21, 2019, at 10:40 p.m., she was passing by Resident 1's room and heard Resident 1 told his roommate (Resident 2) "I'm going to close that door and kick your ass if you don't shut up." The RN stated Resident 1 was talking to his roommate who was in the room lying in bed. The RN stated Resident 2 told her to stop Resident 1. The RN stated she texted (sent a cell phone message) the Director of Nursing (DON) approximately within the hour of the incident on June 21, 2019, to notify the DON of the alleged incident between Residents 1 and 2. On July 16, 2019, at 3:20 p.m., a telephone interview was conducted with the DON. The DON stated she received a text message from the RN on June 21, 2019, which indicated there was an issue with Residents 1 and 2 on June 21, 2019. On July 17, 2019, at 3:46 p.m., an unannounced visit was conducted at the facility. The record of Resident 2 was reviewed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KYZ611 Facility ID: CA240000021 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: _______________ 05A263 (X3) DATE SURVEY COMPLETED 09/26/2019 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 Resident 2 was admitted to the facility on January 24, 2014, with diagnoses which included schizoaffective disorder (a mental disorder). Resident 2's record included a facility document titled, "Progress Notes," dated July 16, 2019. The document indicated: "...Staff followed up with the client regarding incident with male peer on June 21, 2019. When client was asked if he remembered the incident, client stated, "yes I remember, he was using profanity that day..." On July 17, 2019, at 4:35 p.m., the Licensed Vocational Nurse (LVN) was interviewed. The LVN stated when he received an allegation of abuse, he would start the investigation immediately, then he would call and notify the DON or the administrator. The LVN stated he was aware an allegation of abuse should be reported to CDPH within two hours of the incident. On July 16, 2019, at 7:05 p.m., CDPH received a report from the facility about the alleged incident between Residents 1 and 2 on June 21, 2019, via facsimile transmission (a telephonic transmission, 24 days after the alleged verbal abuse incident). The facility policy revised April 2017 titled, "ABUSE PROCEDURE," was reviewed. The policy indicated: "...Client to Client Abuse Procedure...Whenever client to client abuse is alleged, witnessed, reported or suspected to have occurred staff will...call in report to...CDPH within 2 (two) hours..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KYZ611 Facility ID: CA240000021 If continuation sheet 4 of 4