Health inspection·October 9, 2024

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the transfer was appropriate and necessary for one out of three sampled residents (Resident 1), when Resident 1 was transferred to the general acute care hospital (GACH) without documented justification on how needs could not be met at the facility. This failure has the potential to negatively affect resident's needs due to unnecessary transfer. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including fracture (a break or a crack in a bone) of unspecified parts of lumbosacral spine (lower part of the spine) and pelvis (the bones between the lower abdomen and upper thighs). A review of Resident 1's Notice of Transfer/ Discharge Form, dated, September 6, 2024, indicated, .The transfer or discharge is necessary for your welfare and your needs cannot be met in the facility . A review of Resident 1 ' s Interact Transfer Form V5, dated September 6, 2024, indicated, .transfer to hospital per MD order for proper placement . A review of progress notes did not indicate any documented evidence from the resident's physician of the rationale on why Resident 1's need could not be met at the facility, and the rationale on why resident was transferred to the hospital for proper placement. A review of the progress notes titled Interdisciplinary Team (IDT) Notes, dated September 6, 2024, indicated, .Resident is awake and alert, verbally responsive and able to make needs known .Psychotropic regimen of Fluoxetine continued as ordered; no adverse reactions or complications to note. Resident was admitted with pelvic surgical incision, right hip surgical site and skin discoloration to left torso and left lateral knee and left ankle monitor . On September 10, 2024, at 12:10 p.m., during an interview with the Director of Nursing (DON), the DON stated the resident mentioned to the Administrator that he felt not mentally stable, and he needed help. The DON stated the resident was admitted with pelvic fracture and rib fractures but was transferred to the GACH due to the resident verbalizing he needed help. On September 10,2024, at 12:43 p.m., during an interview, the Administrator (Admin) stated Resident (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 2 Event ID: 555404 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 555404 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Village Healthcare Center 17040 Arnold Dr. Riverside, CA 92518 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)