Other·March 20, 2019

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: CA00612872 Representing the California Department of Public Health: Surveyor 37569/3134, HFEN The inspection was limited to the specific complaint allegation investigated and does not represent the findings of a full inspection of the facility. The complaint allegation was unsubstantiated, however, additional violations of the regulations were found, and three deficiencies were issued for complaint number CA00612872.

F607 SS=D Develop/Implement Abuse/Neglect Policies CFR(s): 483.12(b)(1)-(3)

F607 01/15/2019 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95, This REQUIREMENT is not met as evidenced 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: IIG111 Facility ID: CA240000087 If continuation sheet 1 of 10 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 12/31/2018 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 by: Based on interview and record review, the facility failed to ensure new employees were thoroughly screened at the time of hire when three of five employee HR (Human Resources) files reviewed contained no evidence of a completed criminal background check. This failure increased the potential risk for harm to facility residents by allowing unscreened employees with a potential criminal history to provide care to residents. Findings: On November 20, 2018, at 4:18 p.m., an anonymous complaint was received by the California Department of Public Health that alleged on October 21, 2018, a Certified Nursing Assistant (CNA) was heard yelling at a resident (Resident A), telling Resident A to shut-up, and a thump was heard as if Resident A was pushed into the wall. On December 04, 2018, at 9:35 a.m., an unannounced visit was made to the facility for the investigation of the complaint. On December 04, 2018, at 9:45 a.m., the staffing assignment sheets for October 21, 2018 were reviewed and indicated CNA 1, CNA 2, CNA 3, Licensed Vocational Nurse (LVN) 1, and Registered Nurse (RN) 1 were on duty that day. On December 04, 2018, beginning at 11:20 a.m., Resident A's record was reviewed and indicated Resident A was admitted to the facility August 09, 2017, with diagnoses that included dementia (brain disease that causes loss of ability to understand and communicate) and difficulty walking. The History and Physical, dated April 02, 2018, indicated Resident A could make her needs known but could not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IIG111 Facility ID: CA240000087 If continuation sheet 2 of 10 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 12/31/2018 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 make medical decisions. The record indicated Resident A used a walker (device used to assist and support resident when moving around the facility) and required assistance with dressing and feeding. On December 04, 2018, beginning at 12:55 p.m., the employee (HR Human Resources) files for the above named employees were reviewed and indicated the following: -LVN 1 was hired December 04, 2017, and there was no documented indication of a criminal background check in LVN 1's HR file; -RN 1 was hired July 19, 2017, and there was no documented indication of a criminal background check in RN 1's HR file; and -CNA 2 was hired January 03, 2018, and there was no documented indication of a criminal background check in CNA 2's HR file. On December 04, 2018, at 1:25 p.m., the Director of Staff Development (DSD) was interviewed. The DSD stated all newly hired employees should have an electronic criminal background check completed when they were hired and proof of the background check should be in their HR file. The DSD stated the facility conducts a search limited to (name of county) for criminal history using the employee's name and driver's license number. During a concurrent record review, the DSD stated she could find no documented evidence of an electronic criminal background check completed for LVN 1, RN 1, or CNA 2 in their HR files. The facility policy and procedure, titled, "Background Screening Investigations" last revised November 2015, was reviewed and indicated, "...Our facility conducts...criminal conviction investigation checks on direct access employees..."direct access employee" means any individual who has access to a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IIG111 Facility ID: CA240000087 If continuation sheet 3 of 10 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 12/31/2018 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 resident...Such investigation will be initiated within two days of an offer of employment..."

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

F609 01/15/2019 §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 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IIG111 Facility ID: CA240000087 If continuation sheet 4 of 10 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 12/31/2018 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 by: Based on interview and record review, the facility failed to report an allegation of abuse to specified agencies including the California Department of Public Health within two hours, and provide a written report of the findings within 5 days as required. This failure increased the potential risk for harm to facility residents, and the potential risk for allegations of abuse to go unreported and uninvestigated. Findings: On November 20, 2018, at 4:18 p.m., an anonymous complaint was received by the California Department of Public Health (CDPH)that alleged on October 21, 2018, a Certified Nursing Assistant (CNA) was heard yelling at a resident (Resident A), telling Resident A to shut-up, and a thump was heard as if Resident A was pushed into the wall. On December 04, 2018, at 9:35 a.m., an unannounced visit was made to the facility for the investigation of the complaint. On December 04, 2018, beginning at 11:20 a.m., Resident A's record was reviewed and indicated Resident A was admitted to the facility August 09, 2017, with diagnoses that included dementia (brain disease that causes loss of ability to understand and communicate) and difficulty walking. The History and Physical, dated April 02, 2018, indicated Resident A could make her needs known but could not make medical decisions. The record indicated Resident A used a walker (device used to assist and support resident when moving around the facility) and required assistance with dressing and feeding. On December 04, 2018, at 11:55 a.m., the Director of Nursing (DON) was interviewed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IIG111 Facility ID: CA240000087 If continuation sheet 5 of 10 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 12/31/2018 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 DON stated Resident A had no family, was not able to verbalize her needs, and the facility's Interdisciplinary Team made decisions for her. The DON stated another resident (Resident B) reported to the facility's Assistant Administrator (ADM) that Resident B heard a thump while CNA 1 provided care to Resident A on October 21, 2018. The DON stated if an allegation of abuse was made, the ADM did an investigation of the incident and interviewed staff. On December 04, 2018, at 12:10 p.m., the ADM was interviewed. The ADM stated Resident A mumbled and was not able to verbalize her needs. The ADM stated Resident B reported to him on October 23, 2018, that she heard a thump on Resident A's bed on October 21, 2018, when CNA 1 got Resident A ready for bed. The ADM stated he did not report the allegation to CDPH because CNA 1 told him the noise occurred when Resident A slapped him on the face. The ADM stated Resident B did not refuse to have CNA 1 care for her, but was uneasy, and CNA 1 was reassigned to another area of the facility. The facility policy and procedure, titled, "Abuse Investigation and Reporting" last revised July 2017, was reviewed and indicated, "...All reports of resident abuse, neglect...shall be promptly reported to local, state, and federal agencies (as defined by current regulations)...All alleged violations involving abuse...will be reported by the facility Administrator...to...The State licensing/certification agency...The local/State Ombudsman...The Resident's Representative...Adult Protective Services...Law enforcement officials...Attending Physician...Medical Director...immediately, but not later than...Two (2) hours if the alleged violation involves abuse...provide the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IIG111 Facility ID: CA240000087 If continuation sheet 6 of 10 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 12/31/2018 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 appropriate agencies...with a written report of the findings...within five (5) working days of the occurrence of the incident..."

F678 SS=D Cardio-Pulmonary Resuscitation (CPR) CFR(s): 483.24(a)(3)

F678 01/15/2019 §483.24(a)(3) Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure nursing staff maintained current and approved CPR certification (Cardio Pulmonary Resuscitation-life saving measures used to maintain circulation and breathing in emergency), when Licensed Vocational Nurse (LVN) 1 was found to have an expired CPR certificate. This failure increased the potential risk for harm to all facility residents by allowing residents to be cared for by staff without current, approved CPR skills. Findings: On December 04, 2018, at 9:35 a.m., an unannounced visit was made to the facility for the investigation of one complaint. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IIG111 Facility ID: CA240000087 If continuation sheet 7 of 10 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 12/31/2018 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 On December 04, 2018, beginning at 12:55 p.m., the employee (HR Human Resources) file for LVN 1 was reviewed. The file indicated LVN 1 was hired at the facility December 04, 2017. The copy of LVN 1's most recent CPR certificate indicated an expiration date of November 2018. There was no documented indication of a current, approved CPR certificate in LVN 1's HR file. On December 4, 2018, at 1:55 p.m., the Director of Staff Development (DSD) was interviewed. During a concurrent review of LVN 1's HR file, the DSD stated she was unable to find current CPR certification for LVN 1. On December 4, 2018, at 2:15 p.m., the DSD presented a Xerox copy of a CPR card and stated LVN 1 provided the copy to the facility that day. The copy indicated, "(Name of LVN 1)...Issued by (name of company)...Training Site Online Training Holders Signature (blank)..." The area of the card where LVN 1 was supposed to sign when the course was completed was blank. The copy had no documented indication that LVN 1 completed the required hands-on CPR skills demonstration. The card further had no documented indication the course was American Heart Association or American Red Cross approved, as required for approved health care provider CPR courses. On December 10, 2018, at 8:12 a.m., LVN 1 was interviewed by telephone. LVN 1 stated she completed an on-line only CPR course after the facility called her. LVN 1 stated the online course did not include required hands-on CPR skills demonstration and she had not completed any hands-on CPR skills demonstration to renew her CPR certification at the time of the interview. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IIG111 Facility ID: CA240000087 If continuation sheet 8 of 10 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 12/31/2018 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 On December 11, 2018, the Terms and Services site for (name of company) were reviewed online. The Terms indicated, "...If your employer does not accept the certification (name of company) will refund the certification price...The (name of company) is an independent organization...NOT affiliated with any other organization such as American Heart Association (AHA) or American Red Cross (ARC)..." On December 11, 2018, at 4 p.m., the DSD was further interviewed by telephone. The DSD stated CPR certification should be AHA approved. The DSD stated the facility provided on-site CPR renewal classes three to four times a year that included a written test and required hands-on CPR skills demonstration. The DSD stated she received notifications before facility staff's CPR certifications expired and was supposed to alert the employee to renew their CPR certification. The DSD stated LVN 1 should take an AHA approved course to get her CPR certificate renewed. The DSD acknowledged LVN 1 should not be allowed to work if her CPR certificate was expired. The facility policy and procedure, titled, "Job Description...LVN/LPN..." undated, was reviewed and indicated, "...provide direct nursing care to residents...Respond to and monitor care issues and changes in condition...Maintain a current unemcumbered license as a Licensed Vocational/Practical Nurse. Current CPR certification..." §483.24(a)(3) Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IIG111 Facility ID: CA240000087 If continuation sheet 9 of 10 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 12/31/2018 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) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IIG111 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA240000087 (X5) COMPLETE DATE If continuation sheet 10 of 10