Other·February 28, 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 for the investigation of one complaint. Complaint number CA00557509. Representing the California Department of Public Health: Surveyor Federal ID 33841, HFEN. The inspection was limited to the complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for complaint number CA00557509.

F309 SS=D PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING CFR(s): 483.24, 483.25(k)(l)

F309 01/08/2018 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident’s comprehensive assessment and plan of care. 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must 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: 2JX911 Facility ID: CA240000087 If continuation sheet 1 of 9 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: _______________ 055581 (X3) DATE SURVEY COMPLETED 12/20/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JURUPA HILLS POST ACUTE 6401 33rd St Riverside, CA 92509 (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 ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents’ choices, including but not limited to the following: (k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. (l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. This REQUIREMENT is not met as evidenced by: Based on interview, and record review the facility failed to ensure the infected dialysis (treatment that filters and purifies the blood using a machine) site was consistently assessed for one (Resident A) of three sampled residents. This failure to consistently assess could result in being unaware of the skin changes which could contribute in delayed interventions subsequently causing complications and even death. Findings: On November 1, 2017, at 7:35 a.m., an unannounced visit to the facility was conducted to investigate a complaint related to quality care issues. On November 1, 2017, Resident A's record was reviewed. Resident A was readmitted to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2JX911 Facility ID: CA240000087 If continuation sheet 2 of 9 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: _______________ 055581 (X3) DATE SURVEY COMPLETED 12/20/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JURUPA HILLS POST ACUTE 6401 33rd St Riverside, CA 92509 (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 facility on August 7, 2017, with diagnoses which included end stage renal disease (kidneys permanently fail to work). Resident A's physician orders indicated the following: a. January 10, 2017, Check A.V (arteriovenous shunt - used to connect an artery to a vein) for presence of bruit (indicates blood flow by auscultation of artery) and thrill (blood flow on the vascular access by palpating the vibration) upon return from dialysis, then QS (every shift); b. January 10, 2017, Check A.V site dressing QS, leave intact for 4-6 hours following dialysis, change if soiled or fallen off. If bleeding is noted from dialysis access site. Immediately apply pressure to site to stop bleeding. If bleeding does not subside, Call MD (medical doctor) and initiate EMS (emergency medical services) immediately. Every shift; c. October 17, 2017, Vancomycin (antibioticmedication for infection) HCL (hydrochloride) Solution Use 1 gram intravenously (injected into the vein) every Monday, Wednesday, Friday for skin infection until 11/22/17 to be given at dialysis; and d. October 19, 2017, Apply Bactroban (ointment 2% /Mupirocin- antibiotic ointment that prevents bacteria from growing on skin). Apply to right upper arm topically (applied directly to part of the body) every shift for AV fistula (a passage or a hole) surgical site for 21 days cleanse with normal saline (n/s) pat dry apply bactroban ointment 2% add ABD (abdominal dressing) and kerlix wrap QD (once a day) x 21 days. Resident A's TAR (treatment administration record) dated October 1 to 28, 2017, indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2JX911 Facility ID: CA240000087 If continuation sheet 3 of 9 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: _______________ 055581 (X3) DATE SURVEY COMPLETED 12/20/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JURUPA HILLS POST ACUTE 6401 33rd St Riverside, CA 92509 (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 following: a. Resident A's A.V site dressing QS monitoring- indicated a check mark from October 1 to 2, 2017, all shift; and b. Resident A's bactroban treatment indicated a check mark on October 27, 2017. The TAR codes indicated a check mark meant medication/treatment administered. Resident A's progress notes dated October 3, 2017, at 10:51 a.m., indicated, " ...Treatment nurse notified charge nurse of dialysis shunt to right arm was swollen, had drainage coming from it and pain was noted ...patient (Resident A) out to (name of the acute care hospital) for further evaluation ..." Resident A was transferred out to acute care hospital on October 3, 2017, for further evaluation of the swollen dialysis site (right AV shunt). Resident A's acute hospital history and physical dated October 10, 2017, indicated, " ...sent to the ED (emergency department) from his nursing home on 10/3 due to purulent (full of pus) drainage from his (Resident A) right AV fistula. The patient was noted to have an erythematous (redness of the skin), swollen, and tender right arm dialysis shunt with surrounding cellulitis (skin infection) ...might consider ligation (surgical procedure of closing off a blood vessel) of the fistula ..." Resident A's progress notes, indicated the following: a. On October 17, 2017, Resident A was readmitted to the facility with a new dialysis catheter double lumen (medical devices that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2JX911 Facility ID: CA240000087 If continuation sheet 4 of 9 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: _______________ 055581 (X3) DATE SURVEY COMPLETED 12/20/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JURUPA HILLS POST ACUTE 6401 33rd St Riverside, CA 92509 (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 can be inserted in the body) to the left subclavian (situated beneath the clavicle) due to infection of the AV shunt on the right upper arm; b. On October 26, 2017, at 9:23 p.m., " ...receiving IV (intravenous- medication administered through the vein) ABT (antibiotic) r/t (related to) AV shunt infection, 0 ASE (adverse side effect-undesired harmful effect) noted. Resident is currently receiving Dialysis through cvc (central venous catheter- used to administer medication or fluids that are unable to be taken by mouth or would harm a smaller peripheral vein). Site clean and dry ...receiving treatment every shift to AV shunt on right arm ..." c. On October 27, 2017, at 1:55 p.m., " ...IV site is clean, dry, intact, no redness or swelling noted. Tolerating IV abt therapy r/t dialysis shunt infection well. No adverse effects noted ..." d. On October 27, 2017, at 8:10 p.m.," ...resident on monitoring for IV abt r/t dialysis shunt infection, no ase ..." e. On October 27, 2017, at 1:07 a.m., " ...resident on monitoring for IV abt r/t dialysis shunt infection, no ase noted, resident tolerating IV abt therapy well ...g(gastrointestinal) tube intact, no bleeding noted ..." There was no documented evidence the dialysis shunt site's condition was assessed if either worsening or improving due to the antibiotic treatment. f. On October 28, 2017, at 12:46 a.m.," ...resident on monitoring for IV abt antibiotic r/t dialysis shunt infection, no ase noted, resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2JX911 Facility ID: CA240000087 If continuation sheet 5 of 9 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: _______________ 055581 (X3) DATE SURVEY COMPLETED 12/20/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JURUPA HILLS POST ACUTE 6401 33rd St Riverside, CA 92509 (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 tolerating IV abt therapy well, resident on monitoring for skin tear to abdominal area, no bleeding or drainage ..." and g. On October 28, 2017, at 6:40 a.m., late entry, " ...resident tolerating IV abt therapy well, skin intact, with some necrotic (dead) tissue noted to dialysis shunt site, no drainage or oozing coming from the site, dressing on site kept clean and dry. At 5:55 a.m., charge nurse was in a resident room to perform accucheck (blood sugar check). BS (blood sugar) noted to be at 145. Charge nurse asked CNA to change resident and went to finish med pass. Approximately 5 minutes later, charge nurse was called to room of resident, upon arrival to room, charge nurse seen (sic) RN (registered nurse) taking vitals on resident, resident unresponsive, not breathing and unable to obtain pulse. Active bleeding noted from dialysis shunt. Blood found on side of bed, CNA stated she went to change him and pulled back the sheets to find blood. Dressing saturated in blood, pressure applied to dialysis shunt site ..." There was no documented evidence the old AV shunt on the right arm being treated for infection was consistently being assessed either worsening or improving with the antibiotic treatment. The medical director notes dated October 29, 2017, indicated, " ...Patient wound was evaluated by wound specialist on 10/25. During assessment the wound bed was noted as having 25% (percent slough with moderate drainage and erythema to the periwound...In this patient's case he had inflammatory changes visible on the u/s (ultrasound-of imaging which uses high-frequency sound waves to look at organs and structures inside the body) and he already had tissue FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2JX911 Facility ID: CA240000087 If continuation sheet 6 of 9 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: _______________ 055581 (X3) DATE SURVEY COMPLETED 12/20/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JURUPA HILLS POST ACUTE 6401 33rd St Riverside, CA 92509 (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 degradation (deterioration) as evidenced by the ulceration and slough (dead tissue, usually cream or yellow in color) ..." On November 1, 2017, at 7:58 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed. She stated if a dialysis site was bleeding she would apply pressure using a gauze, wrap the site and monitor. LVN 1 stated they did not have an emergency kit used for a bleeding dialysis site at the bedside. She stated they had to get the needed bandages from the treatment cart outside the room. On November 1, 2017, at 10:02 a.m., the Treatment Nurse (TN) was interviewed. She stated the dialysis site should be monitored every shift. She further stated Resident A was receiving antibiotic treatment for the infected old dialysis site on the right upper arm. The TN stated the site should still be monitored every shift for any changes. On November 1, 2017, at 12:51 p.m., LVN 2 was interviewed. She stated she went to check Resident A's blood sugar at around 5:55 a.m. LVN 2 stated Resident A's right arm had a dressing intact during the 5:55 a.m., visit. She stated she asked the certified nursing assistant (CNA) 1 to change Resident A. LVN 2 stated she thought CNA 1 went to the room five (5) minutes after. She (LVN 2) stated Resident A was unresponsive and bleeding from the right arm when she was called by the RN (registered nurse) to Resident A's room on October 28, 2017. On November 1, 2017, at 3:03 p.m., Certified Nursing Assistant (CNA) 1 was interviewed regarding the incident with Resident A on October 28, 2017. She stated she was told by the LVN (LVN 2) to check on Resident A. CNA 1 said she went to the room 5 minutes after she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2JX911 Facility ID: CA240000087 If continuation sheet 7 of 9 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: _______________ 055581 (X3) DATE SURVEY COMPLETED 12/20/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JURUPA HILLS POST ACUTE 6401 33rd St Riverside, CA 92509 (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 was told by LVN 2. She stated when she pulled out the blanket she saw blood from the arm, she called the RN right away. CNA 1 stated there was so much blood, "Tt was scary". On November 2, 2017, at 8:49 a.m., RN 1 was interviewed. She stated CNA 1 called her to look at Resident A. RN 1 stated Resident A looked different and was not waking up. She noticed blood everywhere. It was coming from the old dialysis site on the right arm, and blood was all over the floor. RN 1 stated Resident A's AV shunt dressing was saturated with blood, and was still profusely bleeding. She stated she had to wrap the arm tightly with a blanket and yelled for help. RN 1 stated Resident A had no heartbeat. She stated they called code blue (facility emergency code) and 911. She stated the ambulance staff told her the coroner (a person who would conduct or order an inquest into the manner or cause of death) was called. RN 1 stated the ambulance staff provided instruction not to touch the body until coroner come in. The ambulance company notes dated October 28, 2017, indicated, " ...arrived on scene to a 69 y/o (year old) male (Resident A) who was apneic (cessation of breathing) and pulseless. Patient had hemorrhage (bleeding) through fistula shunt to right upper forearm ...Staff upon our arrival was cleaning blood from floors ...time of death 06:32 a.m...cardiac arrest (sudden, sometimes temporary, cessation of function of the heart) etiology exsanguination (severe loss of blood) ..." The incident report from the sheriff department provided on November 22, 2017, indicated, "...On Saturday, 10-28-2017, around 0714 hours (7:14 a.m.), I (the officer) responded to a call in regards to an unattended death at (name FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2JX911 Facility ID: CA240000087 If continuation sheet 8 of 9 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: _______________ 055581 (X3) DATE SURVEY COMPLETED 12/20/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JURUPA HILLS POST ACUTE 6401 33rd St Riverside, CA 92509 (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 of the skilled nursing facility)... EMT (emergency medical technician- ambulance staff) (name of the EMT) explained they received a call of an unresponsive subject (the deceased) at the nursing facility...they could not resuscitate the deceased...time of death (TOD) at 06:32 hours...(name of EMT) explained when she arrived on scene, there was a large pool of blood on the floor underneath the bed of the deceased...the shunt came loose somehow causing the deceased to bleed out all over the floor...Upon entering the room, the entire scene of the incident was already been (sic) cleaned up by thr nursing staff sometime prior to my (coroner officer) arrival. Therefore, any/all evidence has been discarded at the scene prior to my (coroner officer) at which time I couldn't take photos of the undisturbed scene..I (coroner officer) spoke to the main nurse in charge of the deceased...She (charge nurse) told me (coroner officer) she last checked on the deceased sometime between 0605-0610 (6:05 a.m.- 6:10 a.m.)...the deceased was sleeping in his bed and his vital signs were good prior to leaving the room. (Name of the charge nurse) said she left the room when her certified nursing assistant, (Name of the CNA) told her that the deceased was excessively bleeding out of his wound...she went back into the bedroom and found a large pool of blood on the floor coming from the deceased bed..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2JX911 Facility ID: CA240000087 If continuation sheet 9 of 9