Other·August 6, 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 entity reported incident. Entity Reported Incident Number CA00573592. Representing the California Department of Public Health: Surveyor Federal ID Number 38477, HFEN; and Surveyor Federal ID Number 29337, HFEN. 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 CA00573592.

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

F609 08/07/2018 §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 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: YY7N11 Facility ID: CA240000087 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: _______________ 055581 (X3) DATE SURVEY COMPLETED 07/18/2018 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 later than 24 hours if the events that cause the allegation do not involve abuse and do not 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 interview and record review, the facility failed to ensure an allegation of abuse was reported to the California Department of Public Health (CDPH) immediately, but no later than 2 hours for Resident 1. This failure to notify CDPH had the potential to place all residents in the facility at risk for harm from verbal abuse. Findings: On February 26, 2018, at 1:30 p.m., an unannounced visit was conducted at the facility to investigate an allegation of verbal abuse involving Resident 1. The Assistant Administrator (AD) was interviewed and he stated the incident occurred on February 10, 2018, at 6:30 p.m. On March 15, 2018, at 10:15 a.m., Resident 1's record was reviewed. Resident 1 was admitted FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YY7N11 Facility ID: CA240000087 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: _______________ 055581 (X3) DATE SURVEY COMPLETED 07/18/2018 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 to the facility on July 28, 2016, with diagnoses which included diabetes mellitus (high blood sugar), chronic pain, and anxiety disorder (mood disorder). Resident 1's "History and Physical," dated December 22, 2017, indicated, "...This resident has the capacity to understand and make decisions." The "Nurse's Note," dated February 10, 2018, at 10:37 p.m., indicated, "...At approximately 1830 (6:30 p.m.) writer was called into room. Resident (Patient 1) stated she had her (FMfamily member) call the sheriff because her roommate verbally threatened her..." The care plan, dated February 10, 2018, indicated, "...Resident was involved in an altercation with another resident..." The "IDT (Interdisciplinary Team) Note," dated February 12, 2018, at 2:26 p.m., indicated, "...meeting with (Patient 1) in regards to said incident with another resident (Patient 2) on 2/10/18 (February 10, 2018)...she heard a women's (sic) voice say- Before the nurse gets here you will be in a pile of (inappropriate word) and...I'm gonna kick your (inappropriate word)...(Patient 1) was verbally threatened and said my (FM) called the Police..." On March 15, 2018, at 10:30 a.m., Resident 2's record was reviewed. Resident 2 was admitted to the facility on January 11, 2018, with diagnoses which included fibromyalgia (muscle pain) and major depressive disorder (mood disorder). Resident 2's "History and Physical," dated January 15, 2018, indicated, "...This resident has fluctuating capacity to understand and make decisions..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YY7N11 Facility ID: CA240000087 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: _______________ 055581 (X3) DATE SURVEY COMPLETED 07/18/2018 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 "Progress Notes," dated February 10, 2018, at 10:36 p.m., indicated, "...Resident (Patient 2) stated that roommate (Patient 1) was accusing her of threatening her..." The care plan, dated February 10, 2018, indicated,"...resident was involved in an (sic) verbal altercation with another resident..." On March 15, 2018, the "Confidential Report of Suspected Dependent Adult/Elder Abuse," dated February 10, 2018, completed by Registered Nurse (RN) 1, was reviewed. The report indicated Patient 1 was verbally abused by Patient 2 on February 10, 2018 (no time documented). The report indicated it was transmitted by fax to CDPH on February 12, 2018, at 5:04 p.m. (46 hours after the facility became aware of the allegation). On March 22, 2018, at 9:52 a.m., the AD was interviewed by telephone. The AD stated the facility cannot provide proof the RN 1 faxed it on February 10, 2018. The AD stated the RN 1 should have faxed it within 2 hours. On March 22, 2018, the facility's policy and procedure titled, "Abuse Prevention," dated December 31, 2015, was reviewed. The policy indicated," ...Reporting...Based on F609 42CFR,483.12(c)- The facility is required to report all allegations of abuse, including injuries of unknown source and misappropriation of resident property- must report even if no reasonable suspicion within 2 hours..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YY7N11 Facility ID: CA240000087 If continuation sheet 4 of 4