Other·April 12, 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 two complaints. Complaint numbers CA00557861 and CA00557844. Representing the California Department of Public Health: Surveyor Federal ID number 33841, HFEN. The inspection was limited to the specific complaints investigated and does not represent the findings of a full inspection of the facility. Four deficiencies were issued for complaint numbers CA00557861 and CA00557844. Due to facility's failure to provide an environment free from any verbal and physical abuse from Resident A towards other facility residents, the Administrator and Director of Nursing (DON) were verbally notified of an Immediate Jeopardy situation on October 24, 2017, at 3:30 p.m. (Refer 223) On October 24, 2017, the Administrator and the DON were made aware of four incidents that involved Resident A which had resulted in injuries to other residents, including one death as a result of the resident's injury, at the facility since August 2017. The Immediate Jeopardy was removed at 12:34 p.m., on October 26, 2017, when the facility presented CDPH (California Department of Public Health) with an acceptable plan of 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: R3Z111 Facility ID: CA240000091 If continuation sheet 1 of 40 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 11/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 action. The plan of action indicated the facility would provide a 24 hour direct one on one supervision of Resident A until discharge to a behavioral unit or setting with fewer people.

F223 SS=K FREE FROM ABUSE/INVOLUNTARY SECLUSION CFR(s): 483.12(a)(1)

F223 12/22/2017 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 symptoms. 483.12(a) The facility must(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: Based on observations, interview, and record review, the facility failed to provide five residents (Resident B, C, D, E, and F) in a universe of 137, an environment free from verbal and physical abuse from Resident A. This failure resulted in injuries and feeling of being unsafe, and placing the residents in jeopardy for severe and negative psychosocial response due to ongoing presence of an unsupervised resident who could continue to hurt residents while at the facility. On September 24, 2017, at 3:28 p.m., the Administrator and DON were made aware of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R3Z111 Facility ID: CA240000091 If continuation sheet 2 of 40 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 11/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 observations, interviews, and documented evidence of Resident A's ongoing behaviors towards facility residents. The Administrator and DON were informed of the lack of sufficient measures in place to prevent an increasing environment of physical abuse from one resident (Resident A). Due to the facility's failure to provide an environment free from physical abuse from Resident A, the Administrator and the DON were verbally notified of an Immediate Jeopardy on September 24, 2017, at 3:30 p.m. The Immediate Jeopardy was removed at 12:34 p.m., on October 26, 2017, in the presence of the Administrator, DON, and Assistant Director of Nursing (ADON), after an acceptable plan of action was presented to CDPH (California Department of Public Health), indicating that facility would provide a 24-hour one on one sitter for Resident A until the resident could be transferred to a behavioral facility in accordance to the physician's recommendation. The plan of action indicated: "- Provide direct 1: 1 supervision 24 hours per day until discharge; - Meet with IDT (Interdisciplinary team) to discuss daily plan for safety; - Provide Psychology and Psychiatric evaluation for recommendations; - Discuss condition with (name of physician) for recommendations related to discharge plan and setting and appropriateness; - Contact Public Guardian and send certified letter if unable to contact by telephone; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R3Z111 Facility ID: CA240000091 If continuation sheet 3 of 40 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 11/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 -Continue to make efforts to secure placement in behavioral unit or setting with fewer people; -In-service staff regarding resident safety; and - Provide Social Service visits daily until discharge. " Findings: On October 24, 2017, at 8:30 a.m., an unannounced visit was conducted at the facility to investigate two complaints regarding resident to resident abuse. On October 24, 2017, at 8:50 a.m., Certified Nursing Assistant (CNA) 1 was interviewed. She stated Resident A was blind and could be aggressive. CNA 1 stated the nurses were supposed to take him when he went outside his room. She stated Resident A would try to hit when somebody was in his pathway. On October 24, 2017, at 9 a.m., Resident A was observed sitting in a wheelchair at the corner of the outside patio. There were two residents by the shaded area of the patio and three more residents a few feet away from Resident A. There was no staff member present on the outside patio. On October 24, 2017, at 9:03 a.m., Resident G was interviewed. She stated she knew Resident A. Resident G stated,she "Did not want to mess up with him (pointing at Resident A)." She stated,"If he felt you were near, he (Resident A) will hit you." Resident G stated he FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R3Z111 Facility ID: CA240000091 If continuation sheet 4 of 40 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 11/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 A) would wheel over anybody who tried to be in his way. She stated she heard he (Resident A) hit a female resident, who fell and died. On October 24, 2017, at 9:05 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated Resident A was blind. She stated anybody who saw Resident A should try to avoid him. LVN 1 stated when he (Resident A) went out of his room, he would try to move past anybody. On October 24, 2017, Resident A's record was reviewed. Resident A was re admitted to the facility on July 4, 2014, with diagnoses which included bipolar II disorder ( mental illness that brings severe high and low moods and changes in sleep, energy, thinking, and behavior), schizophrenia ( mental disorder characterized by abnormal social behavior and failure to understand what is real), and blindness. The facility history and physical indicated Resident A did not have a capacity to understand and make decisions. Resident A's MDS (Minimum Data Set- an assessment tool) dated July 22, 2017, Section B (Hearing, Speech, and Vision) indicated, Resident A's vision was coded as severely impaired, which meant, " no vision or sees only light, colors or shapes; eyes do not appear to follow objects." Resident A's eye doctor consultation, dated September 7, 2017, indicated Resident A had cataracts (clouding of the normally clear lens of the eye) on both eyes, and nystagmus (condition of involuntary eye movement). The document further indicated Resident A was uncooperative and agitated during the eye exam. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R3Z111 Facility ID: CA240000091 If continuation sheet 5 of 40 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 11/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 A's progress notes indicated the following: a. December 17, 2016, Resident A had aggressive behavior and an altercation (fight) with roommate; b. March 22, 2017, a resident (Resident B) reported to have been hit by Resident A; c. March 30, 2017, two residents (including Resident B) were witnessed to have hit Resident A; This incident on March 30, 2017, was a few days after Resident A had an altercation with Resident B. d. August 29, 2017, Resident A slapped Resident C's face side to side after Resident C yelled out; e. September 24, 2017, Resident A hit a resident's (Resident D) face four (4) times after being told not to hit; According to progress notes, Resident A had been involved in several altercations from December 2016 to September 2017. Resident A's care plan was reviewed with the ADON on October 24, 2017, at 10:34 a.m. She acknowledged Resident A's care plan did not reflect the incidents involving Resident A's behavior of physical aggression with Resident B, Resident C, and Resident D. Resident A's care plan related to mood disorder was initiated on July 25, 2016, and was revised on September 11, 2016. The care plan indicated Resident A would become upset and would strike out. The interventions were to approach resident in a calm non-threatening FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R3Z111 Facility ID: CA240000091 If continuation sheet 6 of 40 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 11/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 manner, speak in a calm voice, remove people out of resident's pathway when exhibiting behaviors, and assess for possible triggers for behavior. There was no re-evaluation of the care plan to address the resident's increasing behaviors since August 2016. Resident A's psychiatry follow-up notes dated October 11, 2017, indicated Resident A was very irritable, and verbally aggressive. The document indicated staff had reported Resident A's increasing aggressive behavior and the resident (Resident A) had physically hit patients as well as staff. The document further indicated a recommendation to restart depakene (used to treat bipolar mania). There was no documented evidence a care plan was initiated to address Resident A's increasing aggressiveness as noted on the psychiatry notes on October 11, 2017. Resident B's record was reviewed. Resident B was admitted to the facility on May 26, 2017, with diagnoses which included bipolar disorder. The history and physical indicated Resident B had the capacity to understand and make decisions. Resident B's nurse's notes indicated th following: a. On March 22, 2017, Resident B had physical contact with Resident A. The two residents had to be separated. No injuries were noted; b. On March 30, 2017, indicated Resident B reported being hit by Resident A on her face, and right hand. Resident B had skin discoloration and was treated with an ice bag. Resident C's record was reviewed. Resident C was admitted to the facility on August 10, 2009, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R3Z111 Facility ID: CA240000091 If continuation sheet 7 of 40 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 11/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 with diagnoses which included dementia (conditions involving cognitive impairment, with symptoms that include memory loss, personality changes, and issues with language, communication, and thinking), and would intermittently be agitated and combative. The history and physical dated February 7, 2017, indicated Resident C had no decision making capacity. Resident C's change of condition notes, dated August 29, 2017, indicated Resident C was in her wheelchair when Resident A came out and asked about the time. Resident C yelled out and Resident A turned quickly and slapped her face side to side. Resident C was assessed after the incident and was noted with skin tear on her left inner eye and had complained of pain (6/10 on a scale of 1-10 pain level). According to the facility's pain level monitoring guide, a pain level of 6-9 meant severe pain. Resident D's record was reviewed. Resident D was admitted to the facility on September 7, 2017, with diagnoses which included muscle weakness. The history and physical indicated Resident D had the capacity to understand and make decisions. Resident D's nurse's notes dated September 24, 2017, indicated Resident D was coming into facility and asked Resident A if it was ok to let her get out of his way. Resident A hit Resident D in the face four (4) times, in her forehead, eyes, and left bottom lip. Resident D was assessed with laceration on her inner lip after the incident. Resident E's record was reviewed. Resident E was admitted to the facility on December 9, 2013, with diagnoses which included dementia. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R3Z111 Facility ID: CA240000091 If continuation sheet 8 of 40 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 11/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 E's nurse's notes dated October 10, 2017, indicated Resident E had a fall, complained of right hip pain, and was transferred to the acute hospital. Resident E's radiology result dated October 10, 2017, indicated an acute displaced fracture (the bone snaps into two or more parts and moves so that the two ends are not lined up straight) of the femoral (thigh bone) neck (hip fracture) . Resident E's acute hospital history and physical dated October 11, 2017, indicated, "...based on history given by the facility, the patient (Resident E) was pushed out of her wheelchair by another resident at the skilled nursing facility and regretabbly fell and sustained a hip fracture...x-ray (radiologic testing) showing right subcapital (head of thigh bone) hip fracture which was acute (new onset)..." Resident E's acute hospital consultation report dated October 11, 2017, indicated, "...Recommendations: As the patient (Resident E) demonstrates a right hip fracture, this necessitates surgical intrvention...Surgical (physical procedure to correct or relieve injury) intervention is to include a right hemiarthroplasty (hip replacement)..." Resident E's acute hospital death summary report dated October 16, 2017, indicated, "...The patient (Resident E) was admitted to hospice on October 16, 2017, after a hospital stay complicated by hip fracture after being pushed from a wheelchair. Postoperatively, the patient developed a pneumothorax (abnormal collection of air in the chest causing a collapsed lung). She was transferred to ICU (intensive critical unit- caters to patients with severe and life threatening illness and injuries)...her condition never really improved and she continued to deteriorate...expired FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R3Z111 Facility ID: CA240000091 If continuation sheet 9 of 40 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 11/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 shortly thereafter..." The above documentation indicated Resident E had to undergo hip replacement after the fall incident involving Resident A. Resident E expired 6 days after the incident at the facility. Resident F's record was reviewed. Resident F was admitted to the facility on August 4, 2017, with diagnoses which included dementia. Resident F's nurse's notes dated October 20, 2017, indicated Resident F was on his Geri chair in the hallway when he cried out loud when bumped by another resident. Resident F was noted with skin tear on left lower leg (1.5cm (centimeter) x 8 cms or .5 x 8 inches). On October 24, 2017, at 11:05 a.m., Resident B was interviewed. She stated he (Resident A) punched her on one occasion. Resident B stated he (Resident A) hit her friend (Resident D) four times. She further stated he (Resident A) would call everybody "nigger". She stated the staff should watch him. He (Resident A) was always by himself. Resident B further stated she would use the other door to exit to the patio so she would not have to be near him (Resident A). On October 24, 2017, at 11:15 a.m., Resident D was interviewed. She stated he (Resident A) punched her in the face. Resident D stated it was fast, Resident A asked for the time and as she answered him, he (Resident A) reached out and punched her. She stated she just came into the facility and was not aware of his (Resident A) behavior. Resident D further stated she did not think he (Resident A) was blind. She thought he could see. She stated he (Resident A) even called her "bitch". Resident D stated she just want to stay away from him (Resident A). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R3Z111 Facility ID: CA240000091 If continuation sheet 10 of 40 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 11/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 October 24, 2017, at 12:03 p.m., the DON was interviewed. He stated Resident A's behaviors of being aggressive were discussed by the IDT, and interventions were discussed as well. The DON was unable to provide any documented evidence of any IDT notes discussing measures to address the different incidents involving Resident A. On October 25, 2017, at 10:47 a.m., LVN 2 was interviewed. She stated she was the nurse in charge during the incident involving Residents A and Resident E. LVN 2 stated Resident A was in the hallway and suddenly there was a commotion. She saw Resident E on the floor when she went to investigate the commotion. LVN 2 stated Resident E said, "He (Resident A) ran over me." LVN 2 stated Resident E complained of leg pain during the assessment. LVN 2 stated Resident A had to be watched over all the time to be redirected. Resident E's record from the acute hospital dated October 11, 2017, indicated, " ...based on history given by the facility, the patient (Resident E) was pushed out of her wheelchair by another resident at the skilled nursing facility and regrettably fell and sustained a hip fracture ..." On October 25, 2017, at 11:50 a.m., a Physician Assistant (PA) from behavioral health services was interviewed. She stated Resident A had an existing baseline behavior of irritability towards anybody who bumped into him, even on medication or not. The PA stated Resident A needed redirection all the time. She further stated he (Resident A) might be better off in a facility with smaller population due to risk of bumping into a lot of residents which could trigger the behavior of being aggressive towards others. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R3Z111 Facility ID: CA240000091 If continuation sheet 11 of 40 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 11/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 November 6, 2017, at 2:45 p.m., LVN 3 was interviewed regarding the incident involving Residents A and F on October 20, 2017. She stated she saw Resident A come out of the resident's room and make a quick left turn bumping into Resident F who was sitting on a Geri chair by the wall of Room 40. LVN 3 stated Resident F sustained a skin tear on the left leg. She stated Resident A suddenly came out of the room by himself. LVN 3 stated she did not think it was smoking time when Resident A came out of the room. The facility policy and procedure was reviewed. The policy titled, "Abuse Prevention," effective December 31, 2015, indicated," ...Prevention...The staff will identify, correct, and intervene in situations in which abuse, neglect, and/or misappropriation of resident property are more likely to occur. (e.g. physical environment that may make abuse and/or neglect more likely to occur, supervision of staff to identify inappropriate behaviors and the assessment, care planning and monitoring of resident(s) with needs and behaviors which might lead to conflict or neglect.)...Occurrences, patterns and trends will be assessed by administrative staff, licensed staff, and interdisciplinary team to determine the corrective action based on the results of the investigation...If a resident incident is reported, discovered or suspected, where the health, welfare, or safety of the resident (S) is involved, the Center will take steps to provide a safe environment for the resident (s) as indicated by the situation..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R3Z111 Facility ID: CA240000091 If continuation sheet 12 of 40 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 11/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F225 INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS CFR(s): 483.12(a)(3)(4)(c)(1)-(4)

F225 SS=E PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 12/22/2017 483.12(a) The facility must(3) Not employ or otherwise engage individuals who(i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. (4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R3Z111 Facility ID: CA240000091 If continuation sheet 13 of 40 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 11/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 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 longterm care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (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 the alleged violations involving abuse of one (Resident A) towards three residents (Resident C, D, and E) were reported immediately to the State agency. This failure had the potential to result in other incidents of abuse not to be investigated and reported involving Resident A. Findings: On October 24, 2017, at 8:30 a.m., an unannounced visit to the facility was conducted FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R3Z111 Facility ID: CA240000091 If continuation sheet 14 of 40 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 11/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 investigate two complaints regarding resident to resident abuse. On October 24, 2017, at 8:50 a.m., Certified Nursing Assistant (CNA) 1 was interviewed. She stated Resident A was blind and could be aggressive. CNA 1 stated the nurses were supposed to take him when he went outside his room. She stated Resident A would try to hit when somebody was on his pathway. On October 24, 2017, at 9 a.m., Resident A was observed sitting in a wheelchair at the corner of the outside patio. There were two residents by the shaded area of the patio and three more residents a few feet away from Resident A. There was no staff member present on the outside patio. On October 24, 2017, at 9:03 a.m., Resident G was interviewed. She stated she knew Resident A. Resident G stated, she "Did not want to mess up with him (pointing at Resident A)." She stated,"If he felt you were near, he (Resident A) will hit you." Resident G stated he (Resident A) would wheel over anybody who tried to be in his way. She stated she heard he (Resident A) hit a female resident, who fell and died. On October 24, 2017, at 9:05 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated Resident A was blind. She stated anybody who saw Resident A should try to avoid him. LVN 1 stated when he (Resident A) went out of his room, he would try to move past anybody. On October 24, 2017, Resident A's record was reviewed. Resident A was re admitted to the facility on July 4, 2014, with diagnoses which included bipolar II disorder ( mental illness that brings severe high and low moods and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R3Z111 Facility ID: CA240000091 If continuation sheet 15 of 40 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 11/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 changes in sleep, energy, thinking, and behavior), schizophrenia ( mental disorder characterized by abnormal social behavior and failure to understand what is real), and blindness. The facility history and physical indicated Resident A did not have a capacity to understand and make decisions. Resident A's MDS (Minimum Data Set- an assessment tool) dated July 22, 2017, Section B (Hearing, Speech, and Vision) indicated, Resident A's vision was coded as severely impaired, which meant," no vision or sees only light, colors or shapes; eyes do not appear to follow objects." Resident A's eye doctor consultation, dated September 7, 2017, indicated Resident A had cataracts (clouding of the normally clear lens of your eye) on both eyes, and nystagmus (condition of involuntary eye movement). The document further indicated Resident A was uncooperative and agitated during the eye exam. Resident A's progress notes indicated the following: a. December 17, 2016, Resident A had aggressive behavior and an altercation (fight) with roommate; b. March 22, 2017, a resident (Resident B) reported to have been hit by Resident A; c. March 30, 2017, two residents (including Resident B) were witnessed to have hit Resident A; This incident on March 30, 2017, was a few days after Resident A had an altercation with Resident B. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R3Z111 Facility ID: CA240000091 If continuation sheet 16 of 40 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 11/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 d. August 29, 2017, Resident A slapped Resident C's face side to side after Resident C yelled out; e. September 24, 2017, Resident A hit a resident's (Resident D) face four (4) times after being told not to hit; According to progress notes, Resident A had been involved in several altercations from December 2016 to September 2017. Resident A's psychiatry follow-up notes dated October 11, 2017, indicated Resident A was very irritable, and verbally aggressive. The document indicated staff had reported Resident A's increasing aggressive behavior and the resident had physically hit patients as well as staff. Resident C's record was reviewed. Resident C was admitted to the facility on August 10, 2009, with diagnoses which included dementia (conditions involving cognitive impairment, with symptoms that include memory loss, personality changes, and issues with language, communication, and thinking), and would intermittently be agitated and combative. The history and physical dated February 7, 2017, indicated Resident C had no decision making capacity. Resident C's change of condition notes, dated August 29, 2017, indicated Resident C was in her wheelchair when Resident A came out and asked anyone about the time. Resident C yelled out and Resident A turned quickly and slapped her face side to side. Resident C was assessed after the incident and was found to have a skin tear on her left inner eye and had complained of pain (6/10 in a scale of 1-10 pain level). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R3Z111 Facility ID: CA240000091 If continuation sheet 17 of 40 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 11/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 According to the facility's pain level monitoring guide, a pain level of 6-9 meant severe pain. Resident D's record was reviewed. Resident D was admitted to the facility on September 7, 2017, with diagnoses which included muscle weakness. The facility history and physical indicated Resident D had the capacity to understand and make decisions. Resident D's nurse's notes dated September 24, 2017, indicated Resident D was coming into facility and asked Resident A if it was ok to let her get out of his way. Resident A hit Resident D in the face four (4) times, on her forehead, eyes, and left bottom lip. Resident D was assessed with laceration on her inner lip after the incident. Resident E's record was reviewed. Resident E was admitted to the facility on December 9, 2013, with diagnoses which included, dementia. Resident E's nurse's notes dated October 10, 2017, indicated Resident E had a fall, complained of right hip pain, and was transferred to the acute hospital. Resident E's radiology (x-ray-photographic image of the internal composition of a part of the body) result dated October 10, 2017, indicated an acute displaced fracture (the bone snaps into two or more parts and moves so that the two ends are not lined up straight) of the femoral (thigh bone) neck (hip fracture). Resident E's acute hospital history and physical dated October 11, 2017, indicated, "...based on history given by the facility, the patient (Resident E) was pushed out of her wheelchair by another resident at the skilled nursing facility and regretably fell and sustained a hip FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R3Z111 Facility ID: CA240000091 If continuation sheet 18 of 40 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 11/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 fracture...x-ray (radiologic testing) showing right subcapital (head of thigh bone) hip fracture which was acute (new onset)..." Resident E's acute hospital consultation report dated October 11, 2017, indicated, "...Recommendations: As the patient (Resident E) demonstrates a right hip fracture, this necessitates surgical intervention...Surgical ( (physical procedure to correct or relieve injury) intervention is to include a right hemiarthroplasty (hip replacement)..." Resident E's acute hospital death summary report dated October 16, 2017, indicated, "...The patient (Resident E) was admitted to hospice on October 16, 2017, after a hospital stay complicated by hip fracture after being pushed from a wheelchair. Postoperatively, the patient developed a pneumothorax (abnormal collection of air in the chest causing a collapsed lung). She was transferred to ICU (intensive critical unit- caters to patients with severe and life threatening illness and injuries)...her condition never really improved and she continued to deteriorate...expired shortly thereafter..." The above documentation indicated Resident E had to undergo hip replacement after the fall incident involving Resident A. Resident E expired 6 days after the incident at the facility. Resident F's record was reviewed. Resident F was admitted to the facility on August 4, 2017, with diagnoses which included dementia. Resident F's nurse's notes dated October 20, 2017, indicated Resident F was on his Geri chair in the hallway when he cried out loud when bumped by another resident. Resident F was noted with a skin tear on left lower leg (1.5cm (centimeters) x 8 cms or .5 x 3.1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R3Z111 Facility ID: CA240000091 If continuation sheet 19 of 40 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 11/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 inches). On October 24, 2017, at 11:05 a.m., Resident B was interviewed. She stated he (Resident A) punched her on one occasion. Resident B stated he (Resident A) hit her friend (Resident D) four times. She further stated he (Resident A) would call everybody "nigger". She stated the staff should watch him. He (Resident A) was always by himself. Resident B further stated she would use the other door to exit to the patio so she would not have to be near him (Resident A). On October 24, 2017, at 11:15 a.m., Resident D was interviewed. She stated he (Resident A) punched her in the face. Resident D stated it was fast, Resident A asked for the time and as she answered him, the resident (Resident A) reached out and punched her. She stated she just came into the facility and was not aware of Resident A's behavior. Resident D further stated she did not think he (Resident A) was blind, she thought he could see. She stated he (Resident A) even called her "bitch". Resident D stated she just want to stay away from him (Resident A). On October 24, 2017, at 12:03 p.m., the DON was interviewed. He stated Resident A's behaviors were discussed by the IDT, and interventions were discussed as well. The DON was unable to provide any documented evidence of any IDT notes discussing measures to address the different incidents involving Resident A. He stated the incident involving Resident A and Resident E was not reported to the Department because the facility knew the source of Resident E's fracture and it was an accident. The DON stated Resident A had dementia. On October 24, 2017, at 1:20 p.m., the Social FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R3Z111 Facility ID: CA240000091 If continuation sheet 20 of 40 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 11/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 Worker (SW) was interviewed and provided copies of SOC (forms used to report any abuse). She stated the IDT determined to whom a case would be reported. The SW reviewed the SOC letters and indicated the following: a. The incident involving Resident A and B's altercation on March 22, 2017, was reported to Local Ombudsman, police, and CDPH; b. The incident involving Resident A and C (Resident A hit Resident C resulted in injury) on August 29, 2017, was reported to Local Ombudsman only; and c. The incident involving Resident A and D (Resident A punched Resident D on her face with injury) on September 24, 2017, was reported to Local Ombudsman. In a concurrent interview with the SW, she stated the facility followed the guidelines regarding the mandated reporting of any physical abuse. The SW stated Resident A was involved in all the incidents, and he (Resident A) had dementia. There was no documented evidence Resident A was diagnosed of dementia by the facility physician. The document titled, "Mandated Reporter," guideline effective January 1, 2013, was provided by the facility. The guideline indicated, "...Observes, has knowledge of or reasonably suspects Physical abuse in a Long term Care Facility Serious bodily Injury, Immediately: (within 2 hours) Telephone Report to law enforcement and within 2 hours: written report to Ombudsman and Law enforcement and Licensing Agency; No serious Bodily Injury, Within 24 hours: Telephone Report to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R3Z111 Facility ID: CA240000091 If continuation sheet 21 of 40 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 11/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 Law enforcement and Within 24 hours: Written Report To Ombudsman and Law enforcement and Licensing Agency; Caused by resident diagnosed with Dementia by physician; No serious bodily injury, Immediately or as soon as Practicably Possible: Telephone to Ombudsman or Law Enforcement and Within 24 hours: Written Report To Ombudsman or Law Enforcement." On October 25, 2017, at 10:47 a.m., LVN 2 was interviewed. She stated she was the nurse in charge during the incident involving Residents A and Resident E. LVN 2 stated Resident A was at the hallway and suddenly there was a commotion. She saw Resident E on the floor when she went to investigate the commotion. LVN 2 stated Resident E said, "He (Resident A) ran over me." LVN 2 stated Resident E complained of leg pain during the assessment. She stated Resident A had to be watched over all the time to be redirected. The facility policy and procedure was reviewed. The policy titled, "Abuse Prevention, "effective December 31, 2015, indicated, "...Reporting...Any mandated reporter who, in his or her professional capacity, or within the scope of his or her employment has observed or has knowledge of an incident that reasonable appears to be physically abuse...or is told by an elder or dependent adult that he or she has experienced behavior constituting physical abuse...shall report known or suspected abuse...The Administrator shall report all alleged or suspected violations to the appropriate state agencies immediately or within 24 hours (California H & S (Health and Safety Code 1418.91a) and VicePresident of Operations..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R3Z111 Facility ID: CA240000091 If continuation sheet 22 of 40 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 11/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F251 QUALIFICATIONS OF SOCIAL WORKER > 120 BEDS CFR(s): 483.70(p)(1)(2)

F251 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 12/22/2017 (p) Social worker. Any facility with more than 120 beds must employ a qualified social worker on a full-time basis. A qualified social worker is: (1) An individual with a minimum of a bachelor’s degree in social work or a bachelor’s degree in a human services field including, but not limited to, sociology, gerontology, special education, rehabilitation counseling, and psychology; and (2) One year of supervised social work experience in a health care setting working directly with individuals This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to ensure a qualified social worker was employed to provide social services needs for the facility residents of 137. This failure had the potential to result in residents not to receive sufficient and appropriate social services to maintain the highest physical, mental, and psychosocial well-being. Findings: On October 24, 2017, at 8:30 a.m., an unannounced visit to the facility was conducted to investigate two complaints regarding resident to resident abuse. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R3Z111 Facility ID: CA240000091 If continuation sheet 23 of 40 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 11/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 October 24, 2017, Resident A's record was reviewed. Resident A was re admitted to the facility on July 4, 2014, with diagnoses which included bipolar II disorder ( mental illness that brings severe high and low moods and changes in sleep, energy, thinking, and behavior), schizophrenia ( mental disorder characterized by abnormal social behavior and failure to understand what is real), and blindness. The facility history and physical indicated Resident A did not have a capacity to understand and make decisions. Resident A's MDS (Minimum Data Set- an assessment tool) dated July 22, 2017, Section B (Hearing, Speech, and Vision) indicated, Resident A's vision was coded as severely impaired, which meant," no vision or sees only light, colors or shapes; eyes do not appear to follow objects." Resident A's eye doctor consultation, dated September 7, 2017, indicated Resident A had cataracts (clouding of the normally clear lens of your eye) on both eyes, and nystagmus (condition of involuntary eye movement). The document further indicated Resident A was uncooperative and agitated during the eye exam. Resident A's progress notes indicated the following: a. December 17, 2016, Resident A had aggressive behavior and an altercation (fight) with roommate; b. March 22, 2017, a resident (Resident B) reported to have been hit by Resident A; c. March 30, 2017, two residents (including Resident B) were witnessed to have hit FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R3Z111 Facility ID: CA240000091 If continuation sheet 24 of 40 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 11/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 A; This incident on March 30, 2017, was a few days after Resident A had an altercation with Resident B. d. August 29, 2017, Resident A slapped Resident C's face side to side after Resident C yelled out; e. September 24, 2017, Resident A hit a resident's (Resident D) face four (4) times after being told not to hit; According to progress notes, Resident A had been involved in several altercations from December 2016 to September 2017. Resident A's psychiatry follow-up notes dated October 11, 2017, indicated Resident A was very irritable, and verbally aggressive. The document indicated staff had reported Resident A's increasing aggressive and the resident had physically hit patients as well as staff. On October 24, 2017, at 1:20 p.m., the Social Worker (SW) was interviewed and provided copies of SOC (forms used to report any abuse) related to incidents involving Resident A, C, and D. She stated the IDT determined to whom a case would be reported. The SW reviewed the SOC letters and indicated the following: a. The incident involving Resident A and B's altercation on March 22, 2017, was reported to Local Ombudsman, police, and CDPH; b. The incident involving Resident A and C (Resident A hit Resident C resulted in injury) on August 29, 2017, was reported to Local Ombudsman only; and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R3Z111 Facility ID: CA240000091 If continuation sheet 25 of 40 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 11/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 c. The incident involving Resident A and D (Resident A punched Resident D on her face with injury) on September 24, 2017, was reported to Local Ombudsman. In a concurrent interview with the SW, she stated the facility followed the guidelines regarding the mandated reporting of any physical abuse. The SW stated Resident A was involved in all the incidents, and he (Resident A) had dementia. There was no documented evidence Resident A was diagnosed of dementia by the facility physician. The document titled, "Mandated Reporter," guideline effective January 1, 2013, was provided by the facility. The guideline indicated, "...Observes, has knowledge of or reasonably suspects Physical abuse in a Long term Care Facility Serious bodily Injury, Immediately: (within 2 hours) Telephone Report to law enforcement and within 2 hours: written report to Ombudsman and Law enforcement and Licensing Agency; No serious Bodily Injury, Within 24 hours: Telephone Report to Law enforcement and Within 24 hours: Written Report To Ombudsman and Law enforcement and Licensing Agency; Caused by resident diagnosed with Dementia by physician; No serious bodily injury, Immediately or as soon as Practicably Possible: Telephone to Ombudsman or Law Enforcement and Within 24 hours: Written Report To Ombudsman or Law Enforcement." On November 16, 2017, the SW file was reviewed. The file indicated the SW was hired on February 16, 2016, as a SW Director. The document did not indicate if the SW had a bachelor degree related to social work. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R3Z111 Facility ID: CA240000091 If continuation sheet 26 of 40 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 11/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 November 16, 2017, at 11:56 a.m., the SW was interviewed. She stated she had an associate degree in Sociology (the study of social problems). The SW stated she currently did not have a bachelor degree. She further stated she had been working at the facility as a Social Services Director and was not being supervised by any MSW (Master of Social Work- professional degree that enables the holder to practice social work independently). On November 16, 2017, at 12:05 p.m., the SW qualification issue was discussed with the Regional Director of Operations. He was informed of the SW not meeting the criteria for a qualified social worker to work in a facility with more than 120 beds. The Regional Director of Operations was informed of the regulations, requiring the facility to employ a full time qualified social worker who had a minimum of a bachelor's degree in social work or human services field and one year of supervised social work experience.

F323 SS=G FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3)

F323 12/22/2017 (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R3Z111 Facility ID: CA240000091 If continuation sheet 27 of 40 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 11/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure an environment safe and free from any harm was provided for five residents (Resident B, C, D, E, and F) from a universe of 137. The failure to provide adequate supervision to one resident (Resident A) while at the facility had caused injury and harm to five residents (Resident B, C, D, E, and F) while at the facility. Findings: On October 24, 2017, at 8:30 a.m., an unannounced visit to the facility was conducted to investigate a complaint related to resident abuse. On October 24, 2017, at 8:50 a.m., Certified Nursing Assistant (CNA) 1 was interviewed. She stated Resident A was blind. CNA 1 stated Resident A could be aggressive and would hit others. She stated Resident A would run over anybody in his path. CNA 1 stated staff should assist Resident A as soon as he decided to go out of his room to smoke. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R3Z111 Facility ID: CA240000091 If continuation sheet 28 of 40 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 11/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 October 24, 2017, at 9 a.m., Resident A was observed sitting in a wheelchair at the corner of the outside patio. There were two residents by the shaded area of the patio and three more residents a few feet away from Resident A. There was no staff member present on the outside patio. On October 24, 2017, at 9:03 a.m., Resident G was interviewed. She stated she knew Resident A. Resident G stated, she "Did not want to mess up with him (pointing at Resident A)." She stated, "If he felt you were near, he (Resident A) will hit you." Resident G stated he (Resident A) would wheel over anybody who tried to be in his way. She stated she heard he ( Resident A) hit a female resident, who fell and died. On October 24, 2017, at 9:05 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed. She stated Resident A was blind. LVN 1 stated residents should avoid Resident A, since he could not see where he was going. On October 24, 2017, Resident A's record was reviewed. Resident A was re admitted to the facility on July 4, 2014, with diagnoses which included bipolar II disorder ( mental illness that brings severe high and low moods and changes in sleep, energy, thinking, and behavior), schizophrenia ( mental disorder characterized by abnormal social behavior and failure to understand what is real), and blindness. The facility history and physical indicated Resident A did not have a capacity to understand and make decisions. Resident A's MDS (Minimum Data Set- an assessment tool) dated July 22, 2017, Section B (Hearing, Speech, and Vision) indicated, Resident A's vision was coded as severely impaired, which meant, " no vision or sees only FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R3Z111 Facility ID: CA240000091 If continuation sheet 29 of 40 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 11/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 light, colors or shapes; eyes do not appear to follow objects." Resident A's eye doctor consultation, dated September 7, 2017, indicated Resident A had cataracts (clouding of the normally clear lens of your eye) on both eyes, and nystagmus (condition of involuntary eye movement). Resident A's progress notes indicated the following: a. December 17, 2016, Resident A had aggressive behavior and an altercation (fight) with roommate; b. March 22, 2017, a resident (Resident B) reported to have been hit by Resident A; c. March 30, 2017, two residents (including Resident B) was witnessed to have hit Resident A; This incident on March 30, 2017, was few days after Resident A had an altercation with Resident B. d. August 29, 2017, Resident A slapped Resident C's face side to side after Resident C yelled out; e. September 24, 2017, Resident A hit a resident's (Resident D) face four (4) times after saying not to hit her; According to progress notes, Resident A had been involved in several altercations from December 2016 to September 2017. Resident A's care plan was reviewed with the ADON (Assistant Director of Nursing) on October 24, 2017, at 10:34 a.m. She acknowledged Resident A's care plan did not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R3Z111 Facility ID: CA240000091 If continuation sheet 30 of 40 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 11/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 reflect the incidents involving Resident A's physical aggressive behavior towards Resident B, Resident C, and Resident D. There was no documented evidence a care plan to address the ongoing behavior of being physically aggressive towards others was initiated for Resident A. Resident A's psychiatry follow-up notes dated October 11, 2017, indicated, "Pt (patientResident A) was very irritable, verbally aggressive. Staff reports that pt has been increasingly aggressive and has physically hit patients as well as staff." Resident B's record was reviewed. Resident B was admitted to the facility on May 26, 2017, with diagnoses which included bipolar disorder. Resident B's nurse's notes dated March 30, 2017, indicated Resident B reported being hit by Resident A on her face, and right hand. Resident B had skin discoloration and was treated with an ice bag. Resident C's record was reviewed. Resident C was admitted to the facility on August 10, 2009, with diagnoses which included dementia (conditions involving cognitive impairment, with symptoms that include memory loss, personality changes, and issues with language, communication, and thinking), and would intermittently be agitated and combative. Resident C's change of condition notes, dated August 29, 2017, indicated Resident C was in her wheelchair when Resident A came out and asked about the time. Resident C yelled out and Resident A turned quickly and slapped her face side to side. Resident C was assessed after the incident and was found to have a skin tear on her left inner eye and had complained of pain (6/10 on a scale of 1-10 pain level). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R3Z111 Facility ID: CA240000091 If continuation sheet 31 of 40 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 11/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 According to the facility's pain level monitoring guide, a pain level of 6-9 meant severe pain. Resident D's record was reviewed. Resident D was admitted to the facility on September 7, 2017, with diagnoses which included muscle weakness. Resident D's nurse's notes dated September 24, 2017, indicated Resident D was coming into facility and asked Resident A if it was ok to let her get out of his way. Resident A hit Resident D in the face four (4) times, in her forehead, eyes, and left bottom lip. Resident D was assessed with laceration on her inner lip after the incident. Resident E's record was reviewed. Resident E was admitted to the facility on December 9, 2013, with diagnoses which included, dementia. Resident E's nurse's notes dated October 10, 2017, indicated Resident E had a fall, complained of right hip pain, and was transferred to the acute hospital. Resident E's radiology (x-ray-photographic image of the internal composition of a part of the body) ) result dated October 10, 2017, indicated an acute displaced fracture (the bone snaps into two or more parts and moves so that the two ends are not lined up straight) of the femoral (thigh bone) neck (hip fracture). Resident F's record was reviewed. Resident F was admitted to the facility on August 4, 2017, with diagnoses which included dementia. Resident F's nurse's notes dated October 20, 2017, indicated Resident F was in his Geri chair in the hallway, he (Resident F) cried out FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R3Z111 Facility ID: CA240000091 If continuation sheet 32 of 40 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 11/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 loud when bumped by another resident (Resident A). Resident F was noted with a skin tear on left lower leg (1.5cm/ centimeters x 8 cms or 0.5 x 3.1 inches). On October 24, 2017, at 11:05 a.m., Resident B was interviewed. She stated he (Resident A) punched her on one occasion. Resident B stated he (Resident A) hit her friend (Resident D) four times. She further stated he (Resident A) would call everybody "nigger". She stated the staff should watch him. He (Resident A) was always by himself. Resident B further stated she would use the other door to exit so she would not have to be near him. On October 24, 2017, at 11:15 a.m., Resident D was interviewed. She stated he (Resident A) punched her in the face. Resident D stated it was fast. He (Resident A) asked for the time and as she answered him, the resident (Resident A) reached out and punched her. She stated she just came into the facility and was not aware of his (Resident A) behavior. Resident D further stated she did not think he (Resident A) was blind. She thought he could see. She stated he (Resident A) even called her "bitch". On October 24, 2017, at 12:03 p.m., the DON (Director of Nursing) was interviewed. He stated Resident A's behaviors were discussed by the IDT (interdisciplinary team), and interventions were discussed as well. The DON was unable to provide any documented evidence of any IDT notes discussing measures to address the behavior of punching and striking out to any residents he bumped into. On October 25, 2017, at 10:47 a.m., LVN 2 was interviewed. She stated she was the nurse in charge during the incident involving FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R3Z111 Facility ID: CA240000091 If continuation sheet 33 of 40 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 11/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 Residents A and Resident E. LVN 2 stated she heard a commotion during shift change. She stated Resident A was in the hallway and Resident E was already on the floor when she went to investigate the commotion. She stated Resident E said, "He (Resident A) ran over me." LVN 2 stated Resident E complained of leg pain during the assessment. She stated Resident A had to be watched over all the time to be redirected. Resident E's record from the acute hospital dated October 11, 2017, indicated, " ...based on history given by the facility, the patient (Resident E) was pushed out of her wheelchair by another resident at the skilled nursing facility and regrettably fell and sustained a hip fracture ..." Resident E's consultation notes at the acute hospital dated October 11, 2017, indicated, " ...patient demonstrates a right hip fracture, this necessitates surgical (physical procedure to correct injury) intervention ...Surgical intervention is to include right hemi arthroplasty (procedure in which the hip joint is replaced by a prosthetic implant) ..." Resident E's acute hospital death summary report dated October 16, 2017, indicated, "...The patient (Resident E) was admitted to hospice on October 16, 2017, after a hospital stay complicated by hip fracture after being pushed from a wheelchair. Postoperatively, the patient developed a pneumothorax (abnormal collection of air in the chest causing a collapsed lung). She was transferred to ICU (intensive critical unit- caters to patients with severe and life threatening illness and injuries)...her condition never really improved and she continued to deteriorate...expired shortly thereafter..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R3Z111 Facility ID: CA240000091 If continuation sheet 34 of 40 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 11/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 October 25, 2017, at 11:50 a.m., a Physician Assistant (PA) from a behavioral consultation was interviewed. She stated the resident (Resident A) had an existing baseline behavior of irritability towards anybody who bumped into him, even on medication or not. The PA stated the resident (Resident A) needed redirection all the time. She further stated he (Resident A) might be better off in a facility with smaller population which would also decrease the chances of altercations. On November 6, 2017, at 2:45 p.m., LVN 3 was interviewed regarding the incident involving Residents A and F on October 20, 2017. She stated she saw Resident A come out of the resident's room and make a quick left turn bumping into Resident F who was sitting in a Geri chair by the wall of Room 40. LVN 3 stated Resident F sustained a skin tear on the left leg. She stated Resident A suddenly came out of the room by himself. The facility policy and procedure was reviewed. The policy titled, "Abuse Prevention," effective December 31, 2015, indicated," ...Prevention...The staff will identify, correct, and intervene in situations in which abuse, neglect, and/or misappropriation of resident property are more likely to occur. (e.g. physical environment that may make abuse and/or neglect more likely to occur, supervision of staff to identify inappropriate behaviors and the assessment, care planning and monitoring of resident(s) with needs and behaviors which might lead to conflict or neglect.)...Occurrences, patterns and trends will be assessed by administrative staff, licensed staff, and interdisciplinary team to determine the corrective action based on the results of the investigation...If a resident incident is reported, discovered or suspected, where the health, welfare, or safety of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R3Z111 Facility ID: CA240000091 If continuation sheet 35 of 40 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 11/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 (S) is involved, the Center will take steps to provide a safe environment for the resident (s) as indicated by the situation..."

F514 SS=D RES RECORDSCOMPLETE/ACCURATE/ACCESSIBLE CFR(s): 483.70(i)(1)(5)

F514 12/22/2017 (i) Medical records. (1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized (5) The medical record must contain(i) Sufficient information to identify the resident; (ii) A record of the resident’s assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R3Z111 Facility ID: CA240000091 If continuation sheet 36 of 40 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 11/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 (v) Physician’s, nurse’s, and other licensed professional’s progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to ensure the clinical record of one (Resident E) of five sampled residents was complete and accurately reflected the incident of a fall which had occurred on October 10, 2017, while the resident was at the facility. This failure had resulted in unavailability of necessary information related to the fall which could affect appropriate formulation of a treatment plan for Resident E. Findings: On October 24, 2017, at 8:30 a.m., an unannounced visit to the facility was conducted to investigate two complaints regarding resident to resident abuse. On October 24, 2017, at 8:50 a.m., Certified Nursing Assistant (CNA) 1 was interviewed. She stated Resident A was blind and could be aggressive. CNA 1 stated the nurses were supposed to take him when he went outside his room. She stated Resident A would try to hit when somebody was on his pathway. On October 24, 2017, at 9 a.m., Resident A was observed sitting in a wheelchair at the corner of the outside patio. There were two residents by the shaded patio and three more residents a few feet away from Resident A. There was no staff member present on the outside patio. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R3Z111 Facility ID: CA240000091 If continuation sheet 37 of 40 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 11/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 October 24, 2017, at 9:03 a.m., Resident G was interviewed. She stated she knew him (Resident A). Resident G stated, she "Did not want to mess up with him (pointing at Resident A)." She stated,"If he felt you were near, he (Resident A) will hit you." Resident G stated he (Resident A) would wheel over anybody who tried to be in his way. She stated she heard he (Resident A) hit a female resident, who fell and died. Resident E's record was reviewed. Resident E was admitted to the facility on December 9, 2013, with diagnoses which included, dementia (conditions involving cognitive impairment, with symptoms that include memory loss, personality changes, and issues with language, communication, and thinking). Resident E's nurse's notes dated October 10, 2017, indicated Resident E had a fall, complained of right hip pain, and was transferred to the acute hospital. There was no documented evidence in the clinical record describing how Resident E fell on October 10, 2017. Resident E's radiology (x-ray-photographic image of the internal composition of a part of the body) result dated October 10, 2017, indicated an acute displaced fracture (the bone snaps into two or more parts and moves so that the two ends are not lined up straight) of the femoral (thigh bone) neck (hip fracture). On October 25, 2017, at 10 a.m., Licensed Vocational Nurse (LVN) 4 was interviewed. She stated the nurses were supposed to document incidents related to residents. LVN 4 stated change in condition including a fall should be documented in the change of condition and risk management notes (initial FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R3Z111 Facility ID: CA240000091 If continuation sheet 38 of 40 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 11/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 investigation of an incident). On October 25, 2017, at 10:29 a.m., Resident E's record of change of condition was reviewed with the Medical Record Director (MRD). She stated the documentation was incomplete and was not clear on how Resident E fell on October 10, 2017. The MRD stated the nurses should completely document the change of condition of a resident. On October 25, 2017, at 10:47 a.m., LVN 2 was interviewed. She stated she was the nurse in charge during the incident involving Residents A and Resident E. LVN 2 stated Resident A was in the hallway and Resident E was already on the floor when she went to investigate the commotion. She stated Resident E said, "He (Resident A) ran over me." LVN 2 stated Resident E complained of leg pain during the assessment. She stated Resident A had to be watched over all the time to be redirected. Resident E's record from the acute hospital dated October 11, 2017, indicated, " ...based on history given by the facility, the patient (Resident E) was pushed out of her wheelchair by another resident at the skilled nursing facility and regrettably fell and sustained a hip fracture ..." Resident E's consultation notes at the acute hospital dated October 11, 2017, indicated, " ...patient (Resident E) demonstrates a right hip fracture, this necessitates surgical (physical procedure to correct an injury) intervention ...Surgical intervention is to include right hemi arthroplasty (procedure in which the hip joint is replaced by a prosthetic implant) ..." The facility policy and procedure was reviewed. The policy titled, " Charting and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R3Z111 Facility ID: CA240000091 If continuation sheet 39 of 40 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: _______________ 555017 (X3) DATE SURVEY COMPLETED 11/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERWALK POST ACUTE 4000 Harrison St Riverside, CA 92503 (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 Documentation, " revised April 2008, indicated, "...All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record...All observations, medications administered, services performed, etc., must be documented in the resident's clinical records...All incidents, accidents, or changes in the resident's condition must be recorded..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R3Z111 Facility ID: CA240000091 If continuation sheet 40 of 40