Other·December 13, 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 a complaint. Complaint number: CA00602403 Representing the California Department of Public Health: Surveyor 34388, HFEN The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Three deficiencies were issued for complaint number: CA00602403

F550 SS=D Resident Rights/Exercise of Rights CFR(s): 483.10(a)(1)(2)(b)(1)(2)

F550 11/01/2018 §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, 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: 3Q8611 Facility ID: CA240000051 If continuation sheet 1 of 12 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: _______________ 056162 (X3) DATE SURVEY COMPLETED 10/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EXTENDED CARE HOSPITAL OF RIVERSIDE 8171 Magnolia Ave Riverside, CA 92504 (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 discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure that it provided an environment that enhanced quality of life and protected the rights for one of three sampled residents (Resident A) in a universe of 95 residents. This failure occurred when Resident A's family discovered that her hair had been cut without authorization or notification. The facility was unable to determine who cut the resident's hair or exactly when the resident's hair had been cut. This failure had the potential to negatively impact the resident's psychosocial well-being. Findings: On September 12, 2018, at 2:45 p.m., a phone interview was conducted with the complainant. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3Q8611 Facility ID: CA240000051 If continuation sheet 2 of 12 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: _______________ 056162 (X3) DATE SURVEY COMPLETED 10/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EXTENDED CARE HOSPITAL OF RIVERSIDE 8171 Magnolia Ave Riverside, CA 92504 (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 complainant stated that the resident's hair had been kept in a small braid to prevent tangles. The complainant further stated that the resident's braid was observed on Friday August 31, 2018, but when family members had gone to see the resident the following day, Saturday September 1, 2018, the braid had been cut off and the hair had "jagged edges." On September 13, 2018, at 8:40 a.m., an unannounced visit was made to the facility for the investigation of a complaint regarding quality of care and treatment. On September 13, 2018, Resident A's facility medical record was reviewed. Resident A was originally admitted to the facility on November 4, 2016, and readmitted on August 27, 2018, with diagnoses that included disorder of urinary system, metabolic encephalopathy (temporary or permanent disturbance of brain function), ataxia (loss of full control of bodily movement), major depressive disorder (disorder characterized by persistently depressed mood), and dementia (thinking and social symptoms that interfere with daily functioning). Review of Resident A's facility, "History and Physical," (H&P) dated August 29, 2018, indicated, "This resident has fluctuating capacity to understand and make decisions." Further review of Resident A's facility medical record found no documentation of the observation made by the family that the resident's hair had been cut. There was no documentation of any kind in the medical record that addressed the fact that the resident's hair had been cut or that the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3Q8611 Facility ID: CA240000051 If continuation sheet 3 of 12 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: _______________ 056162 (X3) DATE SURVEY COMPLETED 10/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EXTENDED CARE HOSPITAL OF RIVERSIDE 8171 Magnolia Ave Riverside, CA 92504 (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 responsible party or facility department heads were informed of the incident. On September 13, 2018, at 10:57 a.m., an interview was conducted with a certified nursing assistant (CNA 1). CNA 1 confirmed that she had provided care for the resident on the day shift of September 1, 2018. The CNA was asked about Resident A's hair. CNA 1 stated that she honestly did not remember the length of the resident's hair. CNA 1 stated that while she was providing a shower to the resident and washing the resident's hair, the resident was swinging her arms around. CNA 1 further stated, "I don't know what happened to her hair," and stated that she does not remember the length of her hair only that she wanted to get the shower done quickly due to the resident's combativeness. On September 18, 2018, at 9:07 a.m., a phone interview was conducted with the facility's Director of Nursing (DON). The DON was asked about Resident A's hair being cut in the facility. The DON stated that the resident had a "sitter" on the 3:00 p.m. to 11:00 p.m. shift on Friday August 31, 2018. The DON stated that the resident was put to bed at 11:00 p.m. and was observed with the braid at that time. The DON stated that when CNA 1 gave Resident A a shower on Saturday morning, CNA 1 had not noticed the ponytail. The DON further stated that CNA 1 had stated that when she saw the resident in the morning the resident's hair was clean and short. The DON stated that the facility had interviewed all of the staff that had provided care for the resident and no one admitted to cutting the resident's hair. The DON further stated that the resident's family was also questioned and they too denied cutting the resident's hair. The DON stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3Q8611 Facility ID: CA240000051 If continuation sheet 4 of 12 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: _______________ 056162 (X3) DATE SURVEY COMPLETED 10/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EXTENDED CARE HOSPITAL OF RIVERSIDE 8171 Magnolia Ave Riverside, CA 92504 (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 however, "No one has the right to cut anybody's hair." On September 18, 2018, at 10:41 a.m., a phone interview was conducted with CNA 2. CNA 2 confirmed that she had provided care for Resident A on the night shift (11:00 p.m. to 7:00 a.m.) but was unable to state the exact date. CNA 2 stated that Resident A had slept the whole night. CNA 2 stated that she had not paid attention to the length of Resident A's hair and further stated that she honestly could not remember if the resident's hair was long. CNA 2 was asked if she had cut Resident A's hair. CNA 2 stated, "No, I didn't cut her hair." CNA 2 further stated that she would have never cut someone's hair, and stated, "That is ridiculous."

F676 SS=D Activities Daily Living (ADLs)/Mntn Abilities CFR(s): 483.24(a)(1)(b)(1)-(5)(i)-(iii)

F676 11/01/2018 §483.24(a) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that: §483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section ... §483.24(b) Activities of daily living. The facility must provide care and services in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3Q8611 Facility ID: CA240000051 If continuation sheet 5 of 12 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: _______________ 056162 (X3) DATE SURVEY COMPLETED 10/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EXTENDED CARE HOSPITAL OF RIVERSIDE 8171 Magnolia Ave Riverside, CA 92504 (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 accordance with paragraph (a) for the following activities of daily living: §483.24(b)(1) Hygiene -bathing, dressing, grooming, and oral care, §483.24(b)(2) Mobility-transfer and ambulation, including walking, §483.24(b)(3) Elimination-toileting, §483.24(b)(4) Dining-eating, including meals and snacks, §483.24(b)(5) Communication, including (i) Speech, (ii) Language, (iii) Other functional communication systems. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide care and services for activities of daily living (ADLs) for one of three sampled residents (Resident A) in a universe of 95 residents, when Resident A received only one shower in the 8 days she was in the facility. This failure had the potential to negatively affect the resident's physical and psychosocial well-being. Findings: On September 12, 2018, at 2:45 p.m., a phone interview was conducted with the complainant. The complainant stated that she had complained to the facility staff that the resident had not been bathed and that her hair looked greasy. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3Q8611 Facility ID: CA240000051 If continuation sheet 6 of 12 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: _______________ 056162 (X3) DATE SURVEY COMPLETED 10/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EXTENDED CARE HOSPITAL OF RIVERSIDE 8171 Magnolia Ave Riverside, CA 92504 (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 September 13, 2018, at 8:40 a.m., an unannounced visit was made to the facility for the investigation of a complaint regarding quality of care and treatment. On September 13, 2018, Resident A's facility medical record was reviewed. Resident A was originally admitted to the facility on November 4, 2016, and readmitted on August 27, 2018, with diagnoses that included disorder of urinary system, metabolic encephalopathy (temporary or permanent disturbance of brain function), ataxia (loss of full control of bodily movement), major depressive disorder (disorder characterized by persistently depressed mood), and dementia (thinking and social symptoms that interfere with daily functioning). Review of Resident A's facility, "History and Physical," (H&P) dated August 29, 2018, indicated, "This resident has fluctuating capacity to understand and make decisions." Review of the facility shower schedule indicated that by the resident residing in bed C, her assigned shower days were Wednesdays and Saturdays. Review of Resident A's ADL flowsheet for the date range of August 27, 2018, through September 3, 2018, indicated the resident received a partial bed bath on Tuesday August 28th, a full bed bath on Wednesday August 29th, a partial bed bath on Thursday August 30th, a full bed bath on Friday August 31st, a shower on September 1st, a full bed bath on September 2nd and a full bed bath on September 3nd. Per the facility shower schedule, the resident should have received a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3Q8611 Facility ID: CA240000051 If continuation sheet 7 of 12 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: _______________ 056162 (X3) DATE SURVEY COMPLETED 10/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EXTENDED CARE HOSPITAL OF RIVERSIDE 8171 Magnolia Ave Riverside, CA 92504 (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 shower on Wednesday August 29th, but as per the ADL documentation the resident received a full bed bath instead. No further documentation was found in Resident A's record that indicated why the resident had received full bed baths instead of showers or why the resident did not receive a shower on Wednesday August 29, her assigned shower day. On September 18, 2018, at 9:07 a.m., a phone interview was conducted with the facility's Director of Nursing (DON). The DON was asked how many showers the residents were to receive weekly. The DON stated two to three depending on the shower schedule. The DON was asked that if a shower was not given or refused, would the staff be expected to document that it was not given. The DON stated, "Correct." The DON was asked if a resident's hair was washed during a partial or full bath. The DON stated, "No." The DON stated the resident's hair only gets washed on a shower day. Review of a facility policy titled, "Show/Tub Bath," revised October 2010, indicated, "The purpose of this procedure are to promote cleanliness, provide comfort to the resident..." The policy further indicated, "...The following information should be recorded on the resident's ADL and/or in the resident's medical record...5. If the resident refused the shower/tub, the reason(s) why and the intervention taken...1. Notify the supervisor if the resident refuses the shower/tub bath..."

F842 Resident Records - Identifiable Information FORM CMS-2567(02-99) Previous Versions Obsolete

F842 Event ID: 3Q8611 11/01/2018 Facility ID: CA240000051 If continuation sheet 8 of 12 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: _______________ 056162 (X3) DATE SURVEY COMPLETED 10/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EXTENDED CARE HOSPITAL OF RIVERSIDE 8171 Magnolia Ave Riverside, CA 92504 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) SS=D CFR(s): 483.20(f)(5), 483.70(i)(1)-(5) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is(i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3Q8611 Facility ID: CA240000051 If continuation sheet 9 of 12 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: _______________ 056162 (X3) DATE SURVEY COMPLETED 10/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EXTENDED CARE HOSPITAL OF RIVERSIDE 8171 Magnolia Ave Riverside, CA 92504 (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 §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for(i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain(i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to maintain complete and accurate clinical records for one of three sampled residents (Resident A) in a universe of 95 residents when no documentation was made in the medical record that addressed the fact that the resident's hair had been cut or that the responsible party or facility department heads were informed of the incident. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3Q8611 Facility ID: CA240000051 If continuation sheet 10 of 12 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: _______________ 056162 (X3) DATE SURVEY COMPLETED 10/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EXTENDED CARE HOSPITAL OF RIVERSIDE 8171 Magnolia Ave Riverside, CA 92504 (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 September 12, 2018, at 2:45 p.m., a phone interview was conducted with the complainant. The complainant stated that the resident's hair had been kept in a small braid to prevent tangles. The complainant further stated that the resident's braid was observed on Friday August 31, 2018, but when family members had gone to see the resident the following day, Saturday September 1, 2018, the braid had been cut off and the hair had "jagged edges." On September 13, 2018, at 8:40 a.m., an unannounced visit was made to the facility for the investigation of a complaint regarding quality of care and treatment. On September 13, 2018, Resident A's facility medical record was reviewed. Resident A was originally admitted to the facility on November 4, 2016, and readmitted on August 27, 2018, with diagnoses that included disorder of urinary system, metabolic encephalopathy (temporary or permanent disturbance of brain function), ataxia (loss of full control of bodily movement), major depressive disorder (disorder characterized by persistently depressed mood), and dementia (thinking and social symptoms that interfere with daily functioning). Further review of Resident A's facility medical record found no documentation of the observation made by the family that the resident's hair had been cut. There was no documentation of any kind in the medical record that addressed the fact that the resident's hair had been cut or that the responsible party or facility department heads were informed of the incident. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3Q8611 Facility ID: CA240000051 If continuation sheet 11 of 12 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: _______________ 056162 (X3) DATE SURVEY COMPLETED 10/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EXTENDED CARE HOSPITAL OF RIVERSIDE 8171 Magnolia Ave Riverside, CA 92504 (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 September 13, 2018, at 1:04 p.m., an interview was conducted with the facility's Administrator (AD). The AD was informed that after the resident's facility record was reviewed, no documentation was found about the incident of Resident A's hair being cut. The AD was asked if there should have been some documentation in the record that addressed the incident. The AD stated that there should have been some documentation in the record that indicated what was identified and who was notified. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3Q8611 Facility ID: CA240000051 If continuation sheet 12 of 12