Other·October 2, 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 to investigate a complaint. Complaint number: CA00600354 Representing the California Department of Public Health: Surveyor 34388, HFEN The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Two deficiencies were issued for complaint number: CA00600354

F608 SS=D Reporting of Reasonable Suspicion of a Crime F608 CFR(s): 483.12(b)(5)(i)-(iii) 10/18/2018 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. (i) Annually notifying covered individuals, as defined at section 1150B(a)(3) of the Act, of that individual's obligation to comply with the following reporting requirements. (A) Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SHVW11 Facility ID: CA240000091 If continuation sheet 1 of 11 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 09/18/2018 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 facility. (B) Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. (ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act. (iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to implement their policy by failing to report an incident of alleged abuse for one of four sampled residents (Resident A) in a universe of 145 residents. This failure occurred when a facility certified nursing assistant (CNA 1) observed Resident A's cheek being pinched and twisted by another resident (Resident B) in the dining room and no report of the alleged violation was made to the State Agency or other agencies as required. This failure had the potential to result in both physical and psychosocial harm for Resident A and other facility residents. Findings: On August 23, 2018, at 9:43 a.m., an unannounced visit was made to the facility for the investigation of a complaint regarding quality of care and treatment. On August 23, 2018, Resident A's facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SHVW11 Facility ID: CA240000091 If continuation sheet 2 of 11 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 09/18/2018 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 medical record was reviewed. Resident A was admitted to the facility on March 14, 2017, with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (right sided weakness due to a stroke), aphasia (loss of ability to understand or express speech, caused by brain damage), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities). Review of Resident A's facility, "History and Physical," (H&P), dated August 10, 2018, indicated, "This resident does NOT have the capacity to understand and make decisions." Resident A's, "Minimum Data Set," (MDSstandardized assessment for the management of care) dated May 19, 2018, indicated a "BIMS," (brief interview for mental statusscreening tool to assess mental capability) score of 00 out of 15 (scores 00-07 indicate severe impairment). Review of a change in condition (COC) evaluation for Resident A dated August 11, 2018, indicated, "Altercation from another resident." This document was authored by a licensed vocational nurse (LVN 1). Further review of Resident A's facility record found a nursing progress note dated August 11, 2018, at 10:43 p.m., that indicated, "...CNA came to this writer and report (sic) that resident (Resident B's name) pinched and twisted resident (Resident A's name) left cheek. Resident is non verbal (sic) so resident cried out for help. CNA went there to help resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SHVW11 Facility ID: CA240000091 If continuation sheet 3 of 11 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 09/18/2018 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 name) and separate them. Assessment done. No redness or discoloration noted on resident left cheek...RN made aware. Administrator and DON made aware..." LVN 1 also authored this progress note. In review of Resident A's facility record a hand written statement authored by CNA 1 was observed. The hand written statement was dated August 11, 2018. The statement indicated, "I witnessed (Resident B's name) pinching & twisting (Resident A's name) left cheek in the dining room around 6:15 pm. (Resident A's name) was crying out for help since he has no way to defend himself. (Resident B' name) was sent back to his room. Charge nurses, RN (registered nurse) supervisor & Administrator was (sic) notified immediately." CNA 1 signed the statement. Further review of Resident A's facility medical record found no documentation that indicated the State Agency or law enforcement agencies had been notified of Resident A's alleged abuse. There was no documentation found that indicated the State Agency had been notified of the investigation conducted by the facility regarding the resident's alleged abuse. On August 23, 2018, at 11:30 a.m., a phone interview was conducted with LVN 1. LVN 1 was asked if she had witnessed the incident between Resident A and Resident B. LVN 1 stated she had not observed the incident between the two residents but had been informed of it. On August 23, 2018, at 1:53 p.m., a phone interview was conducted with CNA 1. CNA 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SHVW11 Facility ID: CA240000091 If continuation sheet 4 of 11 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 09/18/2018 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 was asked if she had witnessed the incident between Resident A and Resident B. CNA 1 confirmed that she had witnessed the incident between the two residents. CNA 1 stated that while she was in the dining room she had heard Resident A "cry out." CNA 1 stated that Resident A, "can't talk," so the only thing he could do was to cry out. CNA 1 further stated that when she had heard Resident A cry out, she turned to look over and observed Resident B, "twisting and pinching," Resident A's cheek. CNA 1 stated that she could see Resident B, "pulling his skin." CNA 1 stated that Resident A was crying. CNA 1 stated that she had asked Resident A if that had been the first time Resident B had done that. CNA 1 stated that Resident A, "shook his head no." CNA 1 stated that Resident A and Resident B used to be roommates. CNA 1 stated that after the incident she had sent a text to the Administrator (AD), and that she had reported the incident to the RN supervisor, and the charge nurses for both residents. CNA 1 was asked if the incident she had observed between Resident A and Resident B appeared to have been an abusive situation. CNA 1 stated, "Correct." A review of Resident B's facility medical record indicated that the resident was originally admitted to the facility on April 24, 2016, and readmitted on August 7, 2018, with diagnosis that included stimulant abuse, major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities), and diffuse traumatic brain injury with loss of consciousness (sudden, external, physical assault damages the brain). Review of Resident B's facility, "History and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SHVW11 Facility ID: CA240000091 If continuation sheet 5 of 11 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 09/18/2018 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 Physical," (H&P), dated August 7, 2018, failed to indicate if the resident had capacity to make decisions. Resident B's, "Minimum Data Set," (MDSstandardized assessment for the management of care) dated August 14, 2018, indicated a "BIMS," (brief interview for mental statusscreening tool to assess mental capability) score of 15 out of 15 (scores 13-15 indicates cognitively intact). On August 23, 2018, and interview was conducted with the Administrator (AD), and the Director of Nursing (DON). The AD and DON were asked if the allegation of abuse between Resident A and Resident B had been reported to the State Agency. The AD and DON stated that after their investigation, they had determined that there was no allegation of abuse and so it was not reported. Review of a facility policy titled, "Abuse Prevention," dated December 31, 2015, indicated, "Each resident has the right to be free from verbal, sexual, physical and mental abuse...The Center shall take the following steps to prevent, detect and report allegations of abuse..." The policy further indicated, "...All mandated reporters are required by law to report incidents of known or suspected abuse in two ways: 1) by telephone immediately or as soon as practically possible, to the local ombudsman and the local law enforcement agency and 2) by written report, Department of Social Services Form (SOC Form 341), "Report of Suspected Dependent Adult/Elder Abuse: sent within two (2) working days...." The policy indicated, "The Administrator shall report all alleged or suspected violations to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SHVW11 Facility ID: CA240000091 If continuation sheet 6 of 11 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 09/18/2018 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 appropriated state agencies immediately or within 24 hours..."

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

F609 10/18/2018 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SHVW11 Facility ID: CA240000091 If continuation sheet 7 of 11 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 09/18/2018 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 by: Based on interview and record review the facility failed to ensure that it reported an alleged abuse to the State Survey Agency no later than 24 hours after the alleged abuse was observed for one of four sampled residents (Resident A) in a universe of 145 residents. This failure occurred when a facility certified nursing assistant (CNA 1) observed Resident A's cheek being pinched and twisted by another resident (Resident B) in the dining room and no report of the alleged violation was made to the State Agency or other agencies as required. Findings: On August 23, 2018, at 9:43 a.m., an unannounced visit was made to the facility for the investigation of a complaint regarding quality of care and treatment. On August 23, 2018, Resident A's facility medical record was reviewed. Resident A was admitted to the facility on March 14, 2017, with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (right sided weakness due to a stroke), aphasia (loss of ability to understand or express speech, caused by brain damage), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities). Review of a change in condition (COC) evaluation for Resident A dated August 11, 2018, indicated, "Altercation from another resident." This document was authored by a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SHVW11 Facility ID: CA240000091 If continuation sheet 8 of 11 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 09/18/2018 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 licensed vocational nurse (LVN 1). Further review of Resident A's facility record found a nursing progress note dated August 11, 2018, at 10:43 p.m., that indicated, "...CNA came to this writer and report (sic) that resident (Resident B's name) pinched and twisted resident (Resident A's name) left cheek. Resident is non verbal (sic) so resident cried out for help. CNA went there to help resident (Resident A's name) and separate them. Assessment done. No redness or discoloration noted on resident left cheek...RN made aware. Administrator and DON made aware..." LVN 1 also authored this progress note. In review of Resident A's facility record a hand written statement authored by CNA 1 was observed. The hand written statement was dated August 11, 2018. The statement indicated, "I witnessed (Resident B's name) pinching & twisting (Resident A's name) left cheek in the dining room around 6:15 pm. (Resident A's name) was crying out for help since he has no way to defend himself. (Resident B' name) was sent back to his room. Charge nurses, RN (registered nurse) supervisor & Administrator was (sic) notified immediately." CNA 1 signed the statement. Further review of Resident A's facility medical record found no documentation that indicated the State Agency or law enforcement agencies had been notified of Resident A's alleged abuse. There was no documentation found that indicated the State Agency had been notified of the investigation conducted by the facility regarding the resident's alleged abuse. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SHVW11 Facility ID: CA240000091 If continuation sheet 9 of 11 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 09/18/2018 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 A review of Resident B's facility medical record indicated that the resident was originally admitted to the facility on April 24, 2016, and readmitted on August 7, 2018, with diagnosis that included stimulant abuse, major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities), and diffuse traumatic brain injury with loss of consciousness (sudden, external, physical assault damages the brain). On August 23, 2018, at 11:30 a.m., a phone interview was conducted with LVN 1. LVN 1 was asked if she had witnessed the incident between Resident A and Resident B. LVN 1 stated she had not observed the incident between the two residents but had been informed of it. On August 23, 2018, at 1:53 p.m., a phone interview was conducted with CNA 1. CNA 1 was asked if she had witnessed the incident between Resident A and Resident B. CNA 1 confirmed that she had witnessed the incident between the two residents. CNA 1 stated that while she was in the dining room she had heard Resident A "cry out." CNA 1 stated that Resident A, "can't talk," so the only thing he could do was to cry out. CNA 1 further stated that when she had heard Resident A cry out, she turned to look over and observed Resident B, "twisting and pinching," Resident A's cheek. CNA 1 stated that she could see Resident B, "pulling his skin." CNA 1 stated that Resident A was crying. CNA 1 stated that she had asked Resident A if that had been the first time Resident B had done that. CNA 1 stated that Resident A, "shook his head no." CNA 1 stated that Resident A and Resident B used to be roommates. CNA 1 stated that after the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SHVW11 Facility ID: CA240000091 If continuation sheet 10 of 11 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 09/18/2018 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 incident she had sent a text to the Administrator (AD), and that she had reported the incident to the RN supervisor, and the charge nurses for both residents. CNA 1 was asked if the incident she had observed between Resident A and Resident B appeared to have been an abusive situation. CNA 1 stated, "Correct On August 23, 2018, and interview was conducted with the Administrator (AD), and the Director of Nursing (DON). The AD and DON were asked if the allegation of abuse between Resident A and Resident B had been reported to the State Agency. The AD and DON stated that after their investigation, they had determined that there was no allegation of abuse and so it was not reported. Review of a facility policy titled, "Abuse Prevention," dated December 31, 2015, indicated, "Each resident has the right to be free from verbal, sexual, physical and mental abuse...The Center shall take the following steps to prevent, detect and report allegations of abuse..." The policy further indicated, "...All mandated reporters are required by law to report incidents of known or suspected abuse in two ways: 1) by telephone immediately or as soon as practically possible, to the local ombudsman and the local law enforcement agency and 2) by written report, Department of Social Services Form (SOC Form 341), "Report of Suspected Dependent Adult/Elder Abuse: sent within two (2) working days...." The policy indicated, "The Administrator shall report all alleged or suspected violations to the appropriated state agencies immediately or within 24 hours..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SHVW11 Facility ID: CA240000091 If continuation sheet 11 of 11