Other·July 25, 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 the investigation of one facility reported incident. Facility reported incident number: CA00637811. Representing the California Department of Public Health: Surveyor 22921, 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: CA00637811.

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

F609 07/08/2019 §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 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: V9TI11 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 06/20/2019 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 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 report an abuse allegation within two hours to the state survey agency (California Department of Public Health CDPH) when one of three residents reviewed (Resident 1) allegedly hit another resident with the call light. This failed practice caused a delay in the investigation of the allegation by CDPH and the potential to expose the residents of the facility to abuse. Findings: On May 15, 2019, at 9:32 a.m., the facility reported a resident to resident physical altercation between Resident 1 and another resident that occurred on May 15, 2019, at 8 a.m., to CDPH. During a telephone call to the facility by CDPH, on May 15, 2019, at 11:22 a.m., the Director of Nursing (DON) informed CDPH Resident 1 had been involved in a prior altercation on May 11, 2019, at 6:24 a.m. The report regarding the altercation involving FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V9TI11 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 06/20/2019 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 1 which occurred on May 11, 2019, at 6:24 a.m., was not received by CDPH until it was reported by the DON by telephone on May 15, 2019, at 11:22 a.m. (almost 101 hours between the time of the occurrence of the incident and the time of reporting of the incident to CDPH). An unannounced visit was made to the facility on May 22, 2019, beginning at 10:30 a.m. A record review for Resident 1 was conducted on May 22, 2019. The facesheet indicated Resident 1 was re-admitted to the facility on March 21, 2019, with diagnoses that included unspecified dementia (a progressive decline in mental function) without behavioral disturbance. A facility document titled, "...Progress Notes," dated May 11, 2019, at 6:24 a.m., indicated, "...Pt (patient) is found awake and sitting in her wheelchair, in her bedroom, hitting her roommate (roommate's initials) on the hand with her own call light. Immediately, removed (Resident 1's initials) out of the room and assessed her and the roommate...CNA (Certified Nursing Assistant) reported the incident to this writer. MD (Medical Doctor), DON notified..." During an interview with the DON on May 22, 2019, at 3:17 p.m., the DON stated the Registered Nurse (RN) missed sending the report of the incident by fax (telephonic transmission) to CDPH. The DON stated, "we couldn't find a confirmation" the report was sent by fax to CDPH. The facility policy and procedure titled, "Abuse Investigation and Reporting," revised July 2017, was reviewed. The policy indicated, "...Reporting...All alleged violations involving FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V9TI11 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 06/20/2019 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 abuse...will be reported...to the following...The State licensing/certification agency responsible for surveying/licensing the facility...An alleged violation of abuse...will be reported immediately, but not later than...Two (2) hours if the alleged violation involves abuse..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V9TI11 Facility ID: CA240000087 If continuation sheet 4 of 4