Other·January 25, 2018

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 one Entity Reported Incident. Entity Reported Incident: CA00490152. Representing the California Department of Public Health: Surveyor 21211. The inspection was limited to the specific Entity Reported Incident investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for Entity Reported Incident number CA00490152.

F226 SS=D DEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES CFR(s): 483.13(c)

F226 01/16/2018 The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to report abuse for two of three sampled residents (Residents 1 and 2) to the California Department of Public Health (CDPH) within 24 hours. This failure had the potential to place both residents at risk for further abuse not being reported timely to the state agency so that necessary corrective actions could be 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: LWBU11 Facility ID: CA240000043 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: _______________ 055409 (X3) DATE SURVEY COMPLETED 01/11/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COMMUNITY CARE AND REHABILITATION CENTER 4070 Jurupa Ave Riverside, CA 92506 (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 taken depending on the results of the investigation. Findings: On June 6, 2016, at 1:25 p.m., an unannounced visit was made to the facility to investigate a facility reported incident of abuse that occurred on May 28, 2016, at approximately 9:30 p.m., when Resident 1 yelled, cursed and grabbed Resident 2's nightgown by the neck causing the strap to break. In return, Resident 2 then slapped Resident 1 on her face. Resident 2 was interviewed on June 6, 2016, at 2:37 p.m. She stated Resident 3 approached her (Resident 2) on May 28, 2016, at approximately 9:30 p.m., because Resident 3 was having problems with her television working. Resident 2 went over to Resident 3's room to check on the television, and Resident 1 (who was Resident 3's roommate) started yelling, "shut up, shut up," to Resident 2. Resident 1 then called Resident 2 a "Bitch." Resident 2 stated Resident 1 then grabbed Resident 2's nightgown by the neck and pulled it which caused the strap to break. Resident 2 further stated she slapped Resident 1 on her face, and she was getting scared that Resident 1 would choke her (Resident 2). Resident 1 was interviewed on June 6, 2016, at 3:25 p.m. She stated she had been arguing with Resident 2 about the television for Resident 3, and she grabbed Resident 2's nightgown. Resident 1 stated Resident 2 slapped her (Resident 1) on the face. A review of Resident 1's record indicated she was admitted to the facility on February 1, 2016, with diagnoses that included right trochanteric (upper end of the thigh bone) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LWBU11 Facility ID: CA240000043 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: _______________ 055409 (X3) DATE SURVEY COMPLETED 01/11/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COMMUNITY CARE AND REHABILITATION CENTER 4070 Jurupa Ave Riverside, CA 92506 (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 fracture. A review of Resident 2's record indicated she was admitted to the facility on March 2, 2016, with diagnoses that included diabetes mellitus (high blood sugar) and chronic obstructive pulmonary disease (difficulty breathing). A review of the facility's SOC 341 form (a form used to document information on suspected abuse or neglect of an elder or dependent adult) indicated the form was faxed to CDPH on May 31, 2016 (3 days after the abuse occurred). A review of the facility's investigative reports indicated there were no staff witnesses during the incident, and no injuries resulted to either resident. An interview was conducted with the facility Administrator on July 3, 2016, at 1:35 p.m. He stated he was informed on May 28, 2016, after the altercation between Resident 1 and Resident 2 occurred. He stated, "Our policy says to report on weekends ...we thought we could call it in to CDPH on Monday, (May 30, 2016)." The Administrator further stated the facility's policy was to report to CDPH within 24 hours. A review of the facility's undated policy titled "Abuse - Reporting & Investigations" indicated; "...VI. Notification of Outside Agencies of Allegation of Abuse when No Serious Bodily Injury ...C. The administrator or designee will notify Law enforcement, LTC (long term care) Ombudsman, and CDPH (California Department of Public Health) Licensing and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LWBU11 Facility ID: CA240000043 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: _______________ 055409 (X3) DATE SURVEY COMPLETED 01/11/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COMMUNITY CARE AND REHABILITATION CENTER 4070 Jurupa Ave Riverside, CA 92506 (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 Certification by telephone immediately or as soon as practicable, and in writing (SOC 341) within twenty-four (24) hours including weekends of all other allegations of abuse..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LWBU11 Facility ID: CA240000043 If continuation sheet 4 of 4