Inspection·December 11, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from physical abuse by a staff member for one of three residents reviewed (Resident 1) when a Certified Nursing Assistant (CNA) placed a towel over Resident 1's mouth.This failure had the potential to obstruct Resident 1's breathing causing suffocation and the risk of aspiration (inhaling food, liquid, or foreign material into the lungs), and emotional distress.Findings:A review of Resident 1's admission Record indicated he was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (disrupted blood flow to the brain).A review of Resident 1's Minimum Data Set (MDS- a standardized assessment) dated November 3, 2025, indicated he has severely impaired (never/rarely made decisions) capacity to make decisions and dependent with activities of daily living.A review of Resident 1's SBAR (Situation, Background, Assessment, and Recommendation - a structure communication form that helps share information about the condition of a patient) Communication Form and Progress Note dated December 8, 2025, indicated that a CNA (CNA 1) reported an alleged abuse from another CNA (CNA 2) to the resident that occurred on December 6, 2025. Resident 1 was assessed for injuries and was noted to have no issues, and was calm in no distress. Resident 1's physician was notified.On December 11, 2025, at 10:20 a.m., during a concurrent observation and interview, Resident 1 was in his room, lying in bed, with gastric tube feeding (delivering liquid food and medicine directly to the stomach via a tube through the abdominal wall) turned on, alert and awake, non-verbal, and able to mouth words. Resident 1 nodded his head no when asked if a CNA covered his face with a towel.On December 11, 2025, at 11:36 a.m., during a telephone interview, CNA 1 stated on December 6, 2025, between 8:00 p.m. to 9:00 p.m., he was charting outside Resident 1's room when he heard the resident grunting. CNA 1 stated he went to Resident 1's room and found CNA 2 with the resident. CNA 1 stated he asked CNA 2 if she needed help and she said yes. CNA 1 stated as he was helping CNA 2, she threw a towel over Resident 1's face and told the resident be quiet. CNA 1 stated he quickly removed the towel and told CNA 2 that if you tell Resident 1 about what you are going to do, he will cooperate, and you do not treat people like that.On December 11, 2025, at 12:46 p.m., during a telephone interview, CNA 2 stated on December 6, 2025, she was changing Resident 1 and CNA 1 asked her if she needed help. CNA 2 stated she always wears a mask when she provides care to residents, but at that time she didn't have a mask and couldn't find one. CNA 2 stated Resident 1 was coughing so she placed a small towel over Resident 1's mouth to protect herself. CNA 2 stated the towel was on the residents' mouth for at least one minute and Resident 1 removed the towel himself.On December 11, 2025, at 1:11 p.m., during an interview, the Director of Staff Development (DSD) stated during their investigation, CNA 2 mentioned that Resident 1 was coughing, saliva was coming out of his mouth, and she did not have a mask on at that time, so she covered Resident 1's mouth with a towel to prevent the resident from coughing. The DSD stated CNA 2 should have used a mask to protect (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 555330 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Postacute Care 8781 Lakeview Avenue Riverside, CA 92509 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)