Other·October 16, 2019

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 # CA00643950 Representing the California Department of Public Health: Surveyor Federal ID# 36038, 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 CA00643950.

F602 SS=D Free from Misappropriation/Exploitation CFR(s): 483.12

F602 10/05/2019 §483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure the resident is free from misappropriation of property when a Certified Nurse Assistant (CNA) accepted a check worth 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: W8OQ11 Facility ID: CA240000051 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: _______________ 056162 (X3) DATE SURVEY COMPLETED 09/05/2019 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 2,400 dollars given to her by one of the three sampled resident (Resident A). This failure has the potential to negatively affect the psychosocial well-being of Resident A. Findings: On July 9, 2019, at 9:35 a.m., an unannounced visit to the facility was conducted to investigate a facility reported incident regarding an alleged misappropriation of resident's property. On July 9, 2019, at 9:40 a.m., Resident A was interviewed. Resident A stated she wrote a check to a CNA amounting to $2400. She stated the CNA (CNA 1) mentioned to her that she (CNA 1) was in a lot of trouble. Resident A stated, she wrote a check amounting to $2400, and gave the check to the CNA (CNA 1). Resident A's record was reviewed. Resident A was admitted to the facility on June 6, 2019, with diagnoses that included urinary tract infection (infection of the kidney, ureter, bladder, or urethra) and acute metabolic encephalopathy (impairment of brain function resulting from pathophysiological processes). Resident A's History and Physical Examination, dated June 8, 2019, indicated, "Resident A has fluctuating capacity to understand and make decision." A review of the facility document titled, "CONSENT GRIEVANCE REPORTING FORM, " dated June 29, 2019, indicated, Resident A called her bank and noticed the check was cashed out on June 24, 2019. On July 9, 2019, at 9:40 a.m., Resident A stated around 2 weeks ago (June 29, 2019), the responsible party (RP) discovered that Resident A had a missing check, the RP FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W8OQ11 Facility ID: CA240000051 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: _______________ 056162 (X3) DATE SURVEY COMPLETED 09/05/2019 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 investigated and found out that Resident A wrote a check with the amount of $2400 to a CNA. When the RP tried to call the bank to stop the withdrawal of the money (2,400 dollars), the RP found out that the CNA had already withdrawn the check. Resident A stated the RP reported the situation to the facility staff. On July 9, 2019, at 10:51 a.m., the Director of Nursing (DON) was interviewed. The DON stated the staff are not supposed to accept anything from the residents for any reason. On July 9, 2019, at 11:15 a.m., the Director for Staff Development (DSD), was interviewed. The DSD stated, "Staff can't accept anything from the resident." The DSD further stated if the resident were persistent in giving anything, the staff were expected to report the case to the supervisor, DON or to the Administrator. A case report was received on September 3, 2019, from the law enforcement department. The case report indicated, " ...Narrative ... (Resident A's family member/FM statement) ... (name of CNA1) convinced (name of Resident A) to write a check for $ 2,400 (name of CNA 1) could pay for surgery. (Name of CNA 1) was in charge of (name of Resident A) care, and (name of FM) feels as if (name of Resident A) was not in her right frame of mind to be making financial decisions ... (name of CNA 1) told (name of Resident A) that she could not tell anyone about the check or (name of CNA 1) would lose her job. (name of FM) felt that (name of CNA 1) took advantage of (name of Resident A) while (name of Resident A) was in medical crisis ..." The document further indicated," ... (name of Resident A) said she did not feel forced to write the check, but she did not feel safe ..." A review of the facility policy and procedure FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W8OQ11 Facility ID: CA240000051 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: _______________ 056162 (X3) DATE SURVEY COMPLETED 09/05/2019 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 titled, "Abuse -Prevention Program," revised date, November 2018, indicated, "...The facility do not condone any form of resident abuse...Exploitation means taking advantage of resident for personal gain...Misappropriation of Resident Property...exploitation, or wrongful, temporary, or permanent use of resident's...money..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W8OQ11 Facility ID: CA240000051 If continuation sheet 4 of 4