Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Extended Care Hospital Of Riverside during CMS and state inspections, most recent first.
The facility failed to prevent accident hazards and ensure adequate supervision and assistive devices for three residents. A resident who smoked was allowed to keep cigarettes and a lighter at bedside despite documented safety concerns and a policy requiring smoking materials to be maintained by staff, with no evidence of an IDT review or care plan addressing this. Another resident with impaired gait, no decision-making capacity, and identified fall risk required supervised transfers but had a known history of attempting independent transfers that CNAs did not report, and the care plan was not revised before the resident sustained an unwitnessed fall with facial injuries. A third resident with frequent falls and no decision-making capacity was found in bed yelling for help with the call light hanging out of reach, contrary to the care plan and facility policy requiring call lights to be accessible.
Medication services were not carried out according to orders when an LPN gave carvedilol without documenting the required SBP, discontinued meds were left in an active med cart, a Schedule II opioid dose was signed out after the order was discontinued without MAR documentation, and a Lidoderm patch was documented as being applied and removed outside the ordered schedule. The findings involved residents with HTN, heart disease, pain, and other chronic conditions, and staff interviews confirmed the documentation and storage issues.
Failure to Notify Resident Representative About AD: A resident with dementia and no decision-making capacity did not receive an AD offer because of confusion, and the facility did not document follow-up with the resident's RP to provide AD or conservatorship information. The SSD and ADON both confirmed there was no documentation that the RP was contacted regarding AD, despite facility practice requiring contact when a resident cannot consent.
A resident with cirrhosis and fluctuating decision-making capacity was transferred to the hospital for paracentesis, but the facility had no documented evidence that a written transfer notice was provided to the resident or RP before departure. The facility also had no documented evidence that a written bed-hold notice was given, despite policy requiring written notice of transfer/discharge and bed-hold rights to be provided and retained in the resident file.
PASARR screening and referral were not completed for a resident with documented psychosis and major depressive disorder. The record included psychosis, fluctuating capacity, and an Adult Psychosocial Assessment noting depression and multiple mood-related symptoms, yet the PASARR Level I indicated no serious mental illness and no referral was made to the SDA for a Level II eval. The MDS Coordinator stated a new PASARR screening and referral should have been done but was not.
Failure to monitor and document IV site assessments for a resident receiving IV Ertapenem for a UTI. The MAR showed the antibiotic was given daily, but there was no documented evidence that the IV site was checked or assessed each shift. The RNS and ADON both confirmed the lack of documentation, and the facility policy stated IV sites are checked per protocol and PRN for signs of infection.
A resident's gabapentin oral solution was found stored in a med cart at room temperature even though the bottle was labeled to refrigerate it. An LPN confirmed the medication should have been kept in the med refrigerator, and the facility policy and manufacturer instructions both required refrigerated storage.
A resident with a documented nut allergy was served a brownie containing nuts during dining observation. The resident stated he would not eat it because of the allergy and said he could react badly and develop seizures. Records showed allergies to peanuts and tree nuts on the tray card, food allergies to nuts and nitrates in the nutritional assessment, and a physician order for a peanut allergy. The LVN said he did not know the brownie contained nuts and should have checked with dietary staff, and the DSS stated the brownie should not have been served.
Therapeutic Diet Not Followed for A resident With Dysphagia: A resident with dysphagia and no natural teeth had a physician order for a CCHO diet with minced and moist texture and thin liquids, but was served a soft and bite-sized lunch instead. The resident said the chicken was spongy and hard to chew, and two CNAs noted the texture was not appropriate; the resident ate about 25% of the meal. The DSS stated the ordered diet should have been followed.
Expired Tabasco sauce was found on a dry storage shelf and readily available for use. The DSS stated it should have been discarded, and the RD stated expired food items should be discarded because consumption could cause GI illness. The facility policy stated the discard date may not exceed the manufacturer’s use-by date.
Two residents were involved in an incident where one flicked the other on the head, which was documented by staff but not reported to the state agency within the required two-hour timeframe. The delay in reporting was confirmed by the DON, and interviews revealed that some staff were unaware of the reporting requirements. The facility's policy required immediate reporting, but this protocol was not followed.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a deficiency related to the facility's failure to follow the established care plan.
A resident with impaired immunity and a history of UTI exhibited behavioral changes and refused medications and a physician-ordered urinalysis. Staff did not notify the physician of these changes or the treatment refusal until several days later, contrary to facility policy requiring prompt notification of significant changes in condition.
A resident with moderate cognitive impairment reported being scratched and having his arm twisted by his roommate, resulting in visible injuries. Although an LVN was informed of the incident and relayed it to the RN Supervisor, the allegation of abuse was not reported to CDPH within the required two-hour timeframe, as facility policy mandates. The Social Service Director became aware of the incident approximately eleven hours after it occurred, resulting in a delay in reporting.
A resident with documented bipolar and anxiety disorders was admitted after a PASARR Level I screening incorrectly indicated no serious mental illness. MDS nurses confirmed the mental health diagnoses were missed during the screening, which should have triggered a Level II evaluation prior to admission.
A resident with a history of a leg fracture and diabetes was discharged after improvement, but required post-discharge follow-up calls were not documented in the medical record. Interviews with the SSD and DON confirmed that facility policy mandates follow-up calls within 72 hours and again between 14-28 days post-discharge, but there was no evidence these were completed or recorded for the resident.
A facility failed to notify the LTC Ombudsman in a timely manner regarding a resident's discharge. The resident, diagnosed with esophageal cancer, was discharged to another facility with verbal consent. However, the required notice to the Ombudsman was sent four days late, contrary to the facility's policy that mandates prompt notification. This delay could potentially impact the resident's rights and discharge safety.
The facility failed to communicate decisions and rationales regarding issues raised by the Resident Council, leading to a deficiency in honoring residents' rights. Residents reported the dining room was closed at night, limiting access to the patio and vending machine. Staff interviews confirmed the closure, and the Administrator admitted solutions were not shared with the council, violating facility policy.
A resident with moderate cognitive impairment and a history of atelectasis was not assessed for self-administration of medication, despite expressing a desire to do so. The resident had a bottle of Robitussin, not ordered by the facility, visible on their nightstand. Staff interviews revealed a lack of awareness and action regarding the medication, and the facility's policy on self-administration was not followed.
A facility failed to update the PASARR for a resident after new diagnoses of depression and schizoaffective disorder. Initially, the resident had no active psychiatric disorders, but later assessments showed these new conditions. Despite the facility's policy requiring a new PASARR for newly diagnosed mental disorders, no additional screening was completed.
A resident was admitted with bipolar disorder and depression, but the PASARR Level I screening did not reflect these diagnoses, resulting in a negative screening and no Level II evaluation. The DON acknowledged the error, and the Administrator expected adherence to PASARR policy.
A resident with moderate cognitive impairment and physical limitations was not provided with necessary grooming and nail care assistance by the facility staff. Despite policies requiring routine grooming, the resident was observed with long toenails, fingernails, and facial hair. CNAs admitted to not having enough time to perform these tasks, and the DON and Administrator acknowledged the deficiency in care.
A resident with dysphagia was ordered to receive Isosource 1.5 tube feeding, but staff administered Fibersource HN instead, which has a lower caloric content. The LVN relied on a formula exchange sheet and previous day's formula bag, rather than verifying current orders. The RD confirmed the substitution was inappropriate, and the DON and Administrator expected staff to follow physician's orders.
A facility failed to properly store a nebulizer mask between uses for a resident, leading to a deficiency in respiratory care. The facility's policy requires nebulizer equipment to be cleaned, air-dried, and stored in a bag. However, observations revealed the mask was not stored in a bag as required. The resident, with a history of pneumonia, was receiving nebulizer treatments for shortness of breath. Interviews with staff confirmed the expectation to follow the facility's policy.
A resident with a history of low back pain and other conditions did not receive prescribed PRN pain medication despite requesting it before dialysis. The CNA informed the LVN of the request, but the LVN did not administer the medication, and there was no documentation of the medication being given. The facility's pain management policy was not followed.
The facility failed to ensure staff wore required PPE during care for residents on EBP. A resident with a gastrostomy tube and history of ESBL was cared for by an LVN who did not wear a gown during medication administration. Another resident with an ostomy and ESBL history received care from a CNA who did not wear a gown during bed linen changes and a bed bath. Both staff members acknowledged the oversight, and the DON confirmed the expectation for appropriate PPE use.
The facility failed to maintain room temperatures between 71 and 81 degrees Fahrenheit, affecting 46 residents. During an unannounced visit, temperatures in several rooms were observed to be between 82 and 85 degrees. A resident recovering from surgery and another with serious health conditions expressed discomfort due to the heat. The Maintenance Director reported a breaker fuse issue, and the facility's policy on temperature maintenance was not followed.
A facility failed to consistently monitor the weights of two residents upon admission, leading to significant weight changes without proper documentation or intervention. One resident experienced weight fluctuations with no record for the third week, while another resident had a significant weight loss with no documentation after the initial assessment. The registered dietician confirmed the lack of adherence to the facility's weight management policy, which required weekly monitoring and documentation for significant weight changes.
A resident reported that the hot water in his restroom took too long to heat, resulting in cold washcloths during bed baths. Multiple temperature checks confirmed that the water temperature did not reach the required range of 105 to 120 degrees Fahrenheit within a reasonable time frame. Interviews with staff corroborated the issue, and the facility's policy and relevant regulations highlighted the deficiency.
Failure to Prevent Accident Hazards, Falls, and Inaccessible Call Light
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision and assistive devices for three residents. One resident who smoked was observed with cigarettes and a lighter at bedside, despite a smoking assessment documenting safety concerns such as burns to skin, clothing, furniture, and dropping ashes on self, with a recommendation to smoke only with supervision. Facility policy required smoking materials to be maintained by designated staff, and both an LVN and the ADON stated residents were not allowed to keep smoking paraphernalia at bedside without an IDT meeting, physician notification, and care plan in place. There was no documented evidence that such an IDT meeting, physician notification, or care plan had been completed for this resident, and staff were unaware the resident had cigarettes and a lighter at bedside. Another deficiency involved a resident at risk for falls who did not receive adequate supervision and effective fall prevention interventions. This resident had diagnoses including abnormalities of gait and mobility, was assessed as lacking capacity to understand and make decisions, and was identified as at risk for falls. The MDS indicated the resident required supervision or touching assistance for transfers. The resident experienced an unwitnessed fall while attempting to transfer, resulting in facial injuries and hospital transfer. CNAs reported the resident had a history of attempting to transfer independently from wheelchair to bed or toilet, that staff were aware of this behavior, and that one CNA had observed such behavior previously but did not report it to the licensed nurse. The ADON stated CNAs were expected to report unsupervised transfer attempts so that a fall risk assessment and care plan updates could be completed, but the care plan contained no revisions addressing the resident’s behavior of attempting to transfer independently prior to the fall. A third deficiency involved a resident at risk for falls whose call light was not within reach. The resident, who had diagnoses including frequent falls and lacked capacity to understand and make decisions, was heard yelling from her room and was found in bed with the call light hanging to the side of the bed and not within reach. The resident stated she wanted her bedside table moved and was unable to locate her call light. The resident’s care plan documented that the call light should be placed within reach and that the resident needed a prompt response to all requests for assistance. During observation and interview, an LVN confirmed the call light was not within reach and acknowledged that if the call light was not within reach, the resident would be unable to request assistance, including during an emergency. Facility policy required staff to ensure the call light is within reach of the resident and secured as needed.
Medication administration and controlled substance accounting deficiencies
Penalty
Summary
Pharmaceutical services were not provided in accordance with physician orders when a nurse administered carvedilol to a resident with a history of atherosclerotic heart disease and essential hypertension without documenting the systolic blood pressure required by the order. The resident had an order to hold carvedilol if SBP was less than 110 mm Hg or if heart rate was less than 60 beats per minute, but the MAR did not document SBP. During interview, the nurse stated there was no place in the MAR to document SBP and that it could not be documented because there was no field for it. The facility also kept discontinued medications in an active medication cart. During inspection of Cart 1, surveyors found megestrol and hydroxyzine for a resident even though both medications had been discontinued. The nurse interviewed at the time stated the medications should not have been in the cart and should have been discarded properly. The resident’s record confirmed both medications had been discontinued on the dates noted in the report. Controlled substance accounting was inaccurate for a resident’s generic Norco 5 mg. Surveyors found two blister cards and the corresponding CDR in Cart 1, and the CDR showed one dose had been removed and signed out after the medication had already been discontinued. The resident’s record showed no active order after February 1, 2026 and no MAR documentation of administration after that date. In addition, Resident 63’s Lidoderm 5% patch was documented as applied at 9 a.m. and removed at 6 p.m., while staff stated bedtime was 8 or 9 p.m. and the ADON stated the order had been revised to apply the patch for 12 hours.
Failure to Notify Resident Representative About Advance Directives
Penalty
Summary
The facility failed to provide required information and follow up with the resident's representative regarding Advance Directives for a resident who lacked decision-making capacity. Resident 6 was admitted with dementia, and the history and physical stated the resident did not have the capacity to understand and make decisions. The resident's POLST indicated there was no documented advance directive, and the quarterly social service assessment noted that an advance directive was not offered because the resident was confused. The record did not show any documented evidence that the facility followed up with the resident's representative to provide information or education regarding advance directives or conservatorship. During interview, the Social Service Director stated residents were offered advance directive education on admission and during quarterly assessments, and if a resident lacked decision-making capacity, the resident's representative was to be contacted and informed of their rights. The Social Service Director acknowledged that Resident 6 was not offered an advance directive due to confusion and that follow-up with the representative was not conducted as required by facility practice. The ADON also stated there was no documentation that the resident's representative was contacted regarding advance directives.
Failure to Provide Transfer and Bed-Hold Notices
Penalty
Summary
The facility failed to provide a written notice of transfer to Resident 111 or the resident representative at the time the resident was transferred to the hospital for paracentesis. Resident 111’s record showed an admission with diagnoses including cirrhosis of the liver, and the history and physical noted fluctuating capacity to understand and make decisions. A physician progress note documented that the resident’s family had expressed concerns that she needed a paracentesis and requested hospital transfer. The SNF/NF to Hospital Transfer Form documented the transfer, but there was no documented evidence that the required written transfer notice was provided before the resident left the facility. The facility also failed to provide a written bed-hold notice to Resident 111 or the resident representative at the time of transfer. The transfer form indicated that the resident representative was notified of the transfer, but there was no documented evidence that a bed-hold notice was given. During interviews, the ADON stated the licensed nurse was responsible for providing the transfer notice prior to departure, and the DON stated the licensed nurse was responsible for completing the bed-hold form and informing the resident or representative prior to transfer. Facility policies stated that transfer/discharge notices and written bed-hold notices were to be provided to the resident and/or representative and a signed copy kept in the resident’s file.
PASARR Screening and Referral Failure for Resident with Psychosis and Depression
Penalty
Summary
The facility failed to ensure appropriate PASARR screening and referral for one resident who was admitted with documented diagnoses of unspecified psychosis and major depressive disorder. The resident’s record also included a history and physical noting psychosis and fluctuating capacity to understand and make decisions, and an Adult Psychosocial Assessment documenting depression, major depressive disorder, recurrent, moderate, with symptoms including sadness, feeling overwhelmed, irritability, difficulty concentrating, sleep disturbance, fatigue, staying in bed all day, low motivation, feeling on edge, and depressed mood. The assessment also noted a plan to continue vilazodone 20 mg daily. The PASARR Level I in the record indicated that the individual did not have a serious mental illness, despite the documented psychiatric diagnoses and symptoms. There was no documented evidence that the facility corrected the PASARR screening or referred the resident to the State-Designated Authority for a PASARR Level II evaluation after identifying the mental health diagnoses. During interview and record review, the MDS Coordinator stated that the resident had a negative PASARR Level I screening completed by the hospital before admission, that the MDS Section I later reflected psychosis and major depressive disorder, and that a new PASARR screening and referral should have been conducted but was not.
Failure to Monitor and Document IV Site Assessments
Penalty
Summary
The facility failed to monitor and assess the IV site for one resident receiving parenteral fluids and IV antibiotics. Resident 124 was admitted with a diagnosis that included UTI and had a history and physical indicating the resident had the capacity to understand and make decisions. Physician orders dated February 13, 2026, included Ertapenem 500 mg IV every 24 hours for UTI for 7 days, and the MAR showed the antibiotic was administered daily from February 4, 2026, to February 9, 2026. There was no documented evidence that the IV site was monitored or assessed during the period the IV antibiotic was administered. During a concurrent interview and record review, the RNS stated IV sites should be monitored and assessed each shift for complications and documented in the MAR, and acknowledged there was no documented evidence that this was done for Resident 124. The ADON also stated it was the RNS’s responsibility to assess IV sites every shift and document the assessment, and confirmed there was no documented evidence that IV site monitoring or assessments were completed. The facility policy titled Intravenous Therapy stated IV sites are checked per facility protocol and PRN for signs and symptoms of infection, and that IV documentation is recorded in the MAR.
Improper Storage of Refrigerated Medication
Penalty
Summary
The facility failed to ensure medications requiring refrigeration were not stored outside of the refrigerator at room temperature. During observation of Medication Cart 1 at Nursing Station 1, an amber bottle containing approximately 80 mL of gabapentin oral solution for Resident 55 was found in the cart at room temperature with an auxiliary label stating, "Refrigerate." During a concurrent interview, LN 16 confirmed the gabapentin bottle was stored in the cart at room temperature and stated it should have been in the medication refrigerator. Review of the facility's Medication Storage policy showed that medications are to be stored according to the manufacturer's recommendations and that all medications requiring refrigeration are to be stored in refrigerators located in the pharmacy and at each medication room. The manufacturer's prescribing information for gabapentin oral solution indicated it should be stored refrigerated.
Failure to Honor Documented Nut Allergy During Meal Service
Penalty
Summary
The facility failed to provide a diet in accordance with physician's orders for one resident who had a documented allergy to nuts. During dining observation on February 9, 2026, the resident was served a dessert brownie that contained nuts. The resident stated he did not want to eat the brownie because it contained nuts and said he had an allergy to nuts, explaining that he would not eat anything containing nuts because he would react in a bad way and could develop seizures (convulsions). Record review showed the resident's tray card listed allergies to peanuts and tree nuts, the nutritional assessment documented food allergies to nuts and nitrates, and the physician's order listed a food allergy to peanuts. The recipe for the Turtle Brownie (Mix) included pecan pieces. The LVN who checked trays stated he did not know the brownie contained nuts and should have verified the ingredients with dietary staff before delivering the tray. The DSS stated the brownie should not have been served because it contained nuts and that staff should verify ingredients when a resident has a documented allergy.
Therapeutic Diet Not Followed for Resident With Dysphagia
Penalty
Summary
The facility failed to ensure that a physician-ordered therapeutic diet was followed for one resident who had dysphagia and no natural teeth. The resident’s physician order dated February 3, 2026, specified a consistent carbohydrate control diet with minced and moist texture and thin liquids. On February 12, 2026, at lunch, the resident was observed in the dining room being assisted by two CNAs while eating a meal that was served as soft and bite-sized rather than minced and moist. During the observation, the resident stated he was not able to chew the chicken breast because it was spongy and said he could only suck on it, adding that he could have finished the meal if it had been a softer consistency. One CNA stated the meal should have been minced and moist, and the other CNA attempted to cut the chicken with a spoon and stated it was not soft enough and could be difficult to chew. The resident consumed approximately 25% of the meal. The Dietary Service Supervisor later stated the physician’s diet order should have been followed and that not following it created a potential for decreased intake and increased risk for choking.
Expired Food Item Found in Dry Storage
Penalty
Summary
The facility failed to ensure food safety requirements for food storage and preparation were followed when an expired 12-ounce bottle of Tabasco sauce was found on a dry storage shelf and readily available for use. The bottle was labeled with an open date of October 26, 2025, and a manufacturer's best-by date of December 2025, which had expired. During interview, the Dietary Service Supervisor stated the sauce should have been discarded and acknowledged there was potential for food borne illness if the expired product were used. The Registered Dietician later stated expired food items should be discarded and that consumption of expired products could cause gastrointestinal illness. The facility policy on date marking for food safety stated the discard date may not exceed the manufacturer's use-by-date.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of physical abuse involving two residents to the State survey agency within the required two-hour timeframe. One resident, who had dementia and was not capable of making decisions, was flicked on the head by another resident who had chronic obstructive pulmonary disease, polyneuropathy, and depression. The incident was documented in the progress notes, with the aggressor admitting to flicking the other resident on the head to quiet him. There were no witnesses to the event, and the resident who was flicked did not sustain any injuries. Despite the documentation of the incident in the medical record, there was no evidence that the alleged abuse was reported to the California Department of Public Health within two hours as required. The Director of Nursing confirmed that the incident was not reported until seven days after it occurred, after being notified by the Social Service Director who discovered the documentation during a routine review. Interviews with nursing staff revealed a lack of awareness regarding the two-hour reporting requirement for allegations of abuse. The facility's policy required immediate reporting of all alleged violations to the appropriate agencies, specifying a two-hour window in cases of serious bodily injury. However, the staff involved did not follow this protocol, resulting in a delay in notifying the authorities about the incident. The failure to report the allegation in a timely manner was confirmed through interviews, record reviews, and observation.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required.
Failure to Notify Physician of Resident's Change in Condition and Treatment Refusal
Penalty
Summary
The facility failed to notify the physician of a significant change in condition and refusal of treatment for one resident. The resident, who had diagnoses including toxic encephalopathy and a urinary tract infection (UTI), exhibited behavioral changes and refused medications, blood sugar checks, and a physician-ordered urinalysis. Documentation shows that on June 16, the resident refused care and displayed aggressive behaviors, but there was no evidence that the physician was notified of these changes or the refusal to complete the urinalysis at that time. Physician notification did not occur until four days later, despite ongoing noncompliance and worsening behavior. Facility staff interviews confirmed that the refusal and behavioral changes should have been reported to the physician and documented in the medical record, in accordance with facility policy. The lack of timely physician notification and documentation was identified through observation, interview, and record review.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse to the California Department of Public Health (CDPH) within the required two-hour timeframe after the allegation was made. A resident with moderate cognitive impairment and a history of osteomyelitis reported an altercation with his roommate, during which he claimed his arm was twisted and he was scratched, resulting in visible scabbed marks above his wrist. The incident was documented in a social service progress note, and the resident expressed feeling unsafe that night. The roommate confirmed there was a heated exchange but denied physical contact, while a Licensed Vocational Nurse (LVN) stated she was informed by the resident that he had been scratched and reported this to the RN Supervisor, instructing her to notify the DON. Despite the facility's policy requiring all alleged violations to be reported immediately, but no later than two hours after the allegation is made, the Social Service Director became aware of the incident approximately eleven hours after it occurred. The administrator confirmed that abuse allegations should be reported to CDPH within two hours, but this protocol was not followed in this case. The delay in reporting the incident constituted a failure to comply with regulatory requirements for timely reporting of suspected abuse.
PASARR Screening Failed to Identify Resident's Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) Level I screening accurately reflected the presence of diagnosed mental disorders for a resident. Specifically, a resident was admitted with diagnoses including bipolar disorder and anxiety disorder, but the PASARR Level I screening was marked as negative for serious mental illness (SMI). The screening form incorrectly indicated that the resident did not have a serious diagnosed mental disorder, despite documentation of such diagnoses in the admission record. During interviews and record reviews, it was confirmed by two Minimum Data Set Nurses (MDSNs) that the mental health diagnoses were missed during the PASARR screening process. One nurse acknowledged that the question regarding serious mental illness should have been answered affirmatively, and both nurses recognized that this error could have changed the PASARR result from Level I Negative to Level I Positive, which would have required further evaluation prior to admission. The facility's policy states that a positive Level I screen necessitates a Level II evaluation before admission.
Failure to Document Post-Discharge Follow-Up
Penalty
Summary
The facility failed to ensure that a post-discharge follow-up was conducted and documented in the medical record for one resident. The resident, who had a history of a left tibia fracture and type 2 diabetes mellitus, was admitted to the facility and later discharged after his health improved. Documentation review showed that there was no evidence of a follow-up call or contact with the resident after discharge, as required by facility policy. The Social Service Director confirmed that follow-up calls should be made within 72 hours post-discharge and that records of such calls are maintained, but was unable to confirm whether the case manager completed this for the resident in question. Further interviews with the Director of Nursing revealed that both social services and case management are responsible for conducting and documenting follow-up calls at specific intervals after discharge. Review of facility policies confirmed the requirement for timely follow-up calls and accurate documentation in the medical record. However, there was no documentation indicating that the required post-discharge follow-up was completed for the resident, resulting in a deficiency related to discharge planning and documentation.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to ensure timely notification to the Office of the State Long-Term Care Ombudsman regarding the proposed transfer or discharge of a resident. Specifically, the facility did not notify the Ombudsman until four days after the resident had been discharged. The resident, who had been admitted with a diagnosis of esophageal cancer, was discharged to another facility. Although the resident had given verbal consent to the discharge plan, the Social Services Director (SSD) did not send the required notice to the Ombudsman on the day the resident received the discharge notice. The facility's policy requires that the notice of transfer or discharge be provided to the resident and the LTC Ombudsman as soon as practicable before the transfer or discharge. However, the SSD admitted to not following this protocol, as there was no evidence that the Ombudsman was notified on the appropriate date. This oversight could potentially result in the resident lacking an advocate to protect their rights and ensure an appropriate and safe discharge plan.
Failure to Communicate Resident Council Decisions
Penalty
Summary
The facility failed to ensure that staff discussed decisions and rationales regarding issues raised by the Resident Council, which led to a deficiency in honoring residents' rights to organize and participate in resident/family groups. Interviews with residents revealed that the dining room, which provides access to the patio and vending machine, was closed at night, limiting their ability to socialize, relax, and access amenities. Despite residents expressing concerns about the dining room's closure during Resident Council meetings, the facility did not communicate the solutions or their rationale to the council. Interviews with staff, including a CNA, Dietary Service Supervisor, and the Registered Nurse Supervisor, confirmed the dining room was locked at night, contrary to the Assistant Director of Nursing's statement that it should only be closed. The Administrator acknowledged that while solutions were developed to address the issue, they were not shared with the Resident Council. The facility's policy requires that decisions be communicated to the council, which was not adhered to in this case. The residents involved were capable of making decisions, as indicated by their medical records.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident for self-administration of medication, despite the resident expressing a desire to do so. The facility's policy supports residents' rights to self-administer medications, contingent upon an interdisciplinary team assessment to ensure safety. However, the resident, who had a moderate cognitive impairment and a medical history of atelectasis, was not assessed for self-administration. The resident had a bottle of Robitussin, brought by a family member, visible on their nightstand, which was not ordered by the facility and was not included in the resident's medication orders. Interviews with staff revealed a lack of awareness and action regarding the presence of the medication at the resident's bedside. CNAs and an LVN were unaware of the medication, and the LVN confirmed that no assessment for self-administration had been conducted. The Director of Nursing and the Administrator both stated that no residents were approved for self-administration of medications, and the presence of the medication should have been reported and assessed according to facility policy. The oversight resulted in a failure to adhere to the facility's policy on medication self-administration.
Failure to Update PASARR Following New Mental Health Diagnoses
Penalty
Summary
The facility failed to submit a new Preadmission Screening and Resident Review (PASARR) for a resident following the diagnosis of new mental disorders. The resident was admitted with no active psychiatric or mood disorders, as indicated by the initial PASARR Level I screening. However, subsequent assessments revealed the resident was diagnosed with depression and schizoaffective disorder. Despite these new diagnoses, the facility did not complete an additional PASARR Level I screening as required by their policy. Interviews with the Director of Nursing and the Administrator confirmed that a new PASARR should have been completed following the resident's new mental health diagnoses. The facility's policy mandates that any resident exhibiting a newly evident or possible serious mental disorder should be referred for a Level II resident review. The failure to adhere to this policy resulted in the deficiency noted in the report.
Inaccurate PASARR Screening for Resident
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) Level I screening accurately reflected the presence of diagnosed mental disorders for a resident. The resident was admitted with a medical history that included unspecified bipolar disorder and depression, but the PASARR Level I screening completed by a local hospital did not reflect these diagnoses. As a result, the screening was marked as negative, and a Level II evaluation was not conducted. Interviews with facility staff revealed that the MDS Coordinator and the Director of Nursing (DON) were responsible for reviewing PASARR screenings for accuracy. The DON acknowledged that the PASARR for the resident was inaccurate and should have been corrected. The Administrator expected staff to adhere to the facility's policy for PASARRs, which was not followed in this instance, leading to the deficiency.
Failure to Assist Resident with Grooming and Nail Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident who required substantial assistance due to moderate cognitive impairment and physical limitations following a stroke. The resident, who had hemiplegia and hemiparesis affecting one side of the body, was observed with long toenails, fingernails, and facial hair, indicating a lack of grooming and nail care. Despite the facility's policies requiring routine grooming and nail care, the staff did not assist the resident adequately, leaving the resident with untrimmed nails and unshaven facial hair. Interviews with Certified Nursing Assistants (CNAs) and a Licensed Vocational Nurse (LVN) revealed that the CNAs were responsible for grooming tasks, but they failed to perform these duties due to time constraints. The CNAs admitted to not having enough time to shave the resident or trim their nails, and one CNA did not report the resident's long toenails to anyone. The Director of Nursing (DON) and the Administrator confirmed that it was unacceptable for staff to neglect these tasks and expected residents to be groomed as needed. The resident expressed discomfort due to the condition of their toenails, further highlighting the deficiency in care provided by the facility.
Failure to Administer Correct Tube Feeding Formula
Penalty
Summary
The facility failed to provide the correct tube feeding formula as ordered for a resident, leading to a potential nutritional deficiency. The resident, who had a history of dysphagia following a stroke and was receiving nutrition via a feeding tube, was ordered to receive Isosource 1.5 at a rate of 60 mL per hour for 16 hours daily. However, staff provided Fibersource HN instead, which has a lower caloric content, potentially leading to insufficient caloric intake. Observations revealed that the incorrect formula was administered on multiple occasions, and the staff responsible for the resident's care did not follow the updated physician's orders. The Licensed Vocational Nurse (LVN) involved relied on a formula exchange sheet and the previous day's formula bag, rather than verifying the current orders. The Registered Dietitian (RD) confirmed that the substitution was not appropriate and that she had not been consulted about the change. Interviews with the Director of Nursing (DON) and the Administrator indicated that staff were expected to follow physician's orders and consult the RD or physician if the ordered formula was unavailable. Despite these expectations, the LVN did not verify the updated orders, leading to the administration of an incorrect formula, which was not a comparable exchange for the ordered Isosource 1.5.
Improper Storage of Nebulizer Mask
Penalty
Summary
The facility failed to properly store a nebulizer mask between uses for a resident, leading to a deficiency in respiratory care. The facility's policy on nebulizer therapy, revised in February 2024, specifies that nebulizer equipment should be cleaned after each use, disassembled, rinsed with sterile or distilled water, air-dried, and stored in a storage bag once completely dry. However, observations on December 16 and 17, 2024, revealed that the nebulizer mask for Resident #7 was not stored in a bag as required by the policy. Instead, it was found lying on top of the resident's dresser. Resident #7, who was admitted to the facility in November 2024, had a medical history that included pneumonia and was receiving as-needed nebulizer treatments for shortness of breath related to a cough. The resident's care plan included the administration of DuoNeb as ordered. Interviews with LVN #3 and the Director of Nursing confirmed that the nebulizer mask should be stored in a bag when not in use, aligning with the facility's policy. The Administrator also expressed the expectation that staff follow the facility's policy regarding the cleaning and storage of nebulizer masks.
Failure to Administer PRN Pain Medication
Penalty
Summary
The facility failed to provide appropriate pain management for Resident #210, who had a medical history of low back pain, personal history of malignant neoplasm of the breast, and acute kidney failure. The resident was admitted on 12/11/2024 and had orders for Tylenol and Norco for pain management. On 12/16/2024, the resident reported a pain level of 7 out of 10 and requested pain medication before going to dialysis. Despite this request, there was no documented evidence that the resident received the prescribed PRN Tylenol or Norco on that day. The deficiency occurred when CNA #6, after being informed by the resident about the need for pain medication, communicated this to LVN #7. However, LVN #7 could not recall if he was informed about the request and admitted to not administering the pain medication before the resident's dialysis session. The facility's policy on pain management, which requires recognizing and managing pain consistent with the resident's care plan and preferences, was not followed, as confirmed by the Administrator's statement that the medication should have been given upon the resident's complaint of pain.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff wore all required personal protective equipment (PPE) during the provision of care for residents on enhanced barrier precautions (EBP). This deficiency was observed in the care of Resident #18, who had a history of extended-spectrum beta-lactamase (ESBL) and utilized a gastrostomy tube. During a medication administration task, a Licensed Vocational Nurse (LVN) checked the resident's vital signs and administered medications via the feeding tube while wearing gloves but not a gown, contrary to the facility's policy. The LVN admitted to not knowing that a gown was required for such procedures. Similarly, the facility's failure to adhere to EBP was noted in the care of Resident #5, who also had a history of ESBL and an ostomy. A Certified Nursing Assistant (CNA) changed the resident's bed linens and provided a bed bath while wearing a mask and gloves but no gown. The CNA acknowledged that a gown should have been worn due to the resident's EBP status. The Director of Nursing confirmed that the expectation was for staff to wear appropriate PPE, including gowns, when providing care to residents on EBP.
Failure to Maintain Safe Room Temperatures
Penalty
Summary
The facility failed to maintain a safe and comfortable environment for its residents by not ensuring room temperatures were kept between 71 and 81 degrees Fahrenheit. During an unannounced visit, it was observed that the temperatures in several rooms ranged from 82 to 85 degrees Fahrenheit, affecting 46 out of 96 residents. The Maintenance Director reported that a breaker fuse had gone bad, causing the generator power to activate, and they had been working on replacing the fuse throughout the day. Two residents were interviewed during the visit. One resident, who was recovering from surgery, was observed perspiring and expressed discomfort due to the heat. Another resident, who had multiple serious health conditions including acute respiratory failure and chronic congestive heart failure, also expressed discomfort and dissatisfaction with the situation. The facility's policy on maintaining temperatures within the specified range was not adhered to, leading to the substantiated complaint of an uncomfortable environment for the residents.
Failure to Monitor Resident Weights Consistently
Penalty
Summary
The facility failed to weigh two residents, Resident A and Resident B, on admission and weekly for the first four weeks as required to establish a baseline weight. This failure was identified during an unannounced visit on June 10, 2024, for an allegation of quality of care and treatment. Resident A, who was admitted with diagnoses including Type II Diabetes Mellitus, Sepsis, and Alzheimer's, experienced significant weight fluctuations without consistent monitoring. Initial weight was recorded at 173 pounds, followed by a loss to 166 pounds and then 160 pounds, with no weight documented for the third week. The registered dietician (RD) confirmed that the policy required weekly weights for the first four weeks and noted that a 5% weight change in a week is significant and requires closer monitoring. Resident B, admitted with a history of falls and a heart attack, also experienced significant weight loss without consistent monitoring. Initial weight was 118 pounds, dropping to 109 pounds within a week, and further to 103 pounds over the following weeks. The RD noted that a nutritional assessment should be completed within the first two weeks of admission, and progress notes should be added for any weight changes. However, there was no documentation of weight or nutritional progress notes for Resident B after February 7, 2024, despite continued weight loss. The facility's policy on weight management, dated December 19, 2022, outlined the need for a systematic approach to optimize residents' nutritional status, including weekly weight monitoring for newly admitted residents. The policy also required the RD to document weight change notes for significant weight changes. The RD acknowledged the lack of documentation and monitoring for both residents, which was inconsistent with the facility's policy and professional standards of practice.
Failure to Maintain Appropriate Water Temperatures
Penalty
Summary
The facility failed to ensure that the resident's water temperatures were maintained at a comfortable level, as evidenced by the complaint from Resident 1 and subsequent observations. Resident 1, who has a medical history including malignant neoplasm of the lung, secondary malignant neoplasm of the brain, type 2 diabetes mellitus, and atrial fibrillation, reported that the hot water in his restroom took too long to heat, resulting in cold washcloths during bed baths. Multiple temperature checks confirmed that the water temperature in Resident 1's restroom did not reach the required range of 105 to 120 degrees Fahrenheit within a reasonable time frame, with temperatures recorded at 85, 95, 89.5, and 100.6 degrees Fahrenheit at various times during the surveyor's visit. Interviews with facility staff, including a Certified Nursing Assistant (CNA) and the Maintenance Director (MD), corroborated the issue, with the MD acknowledging that the water temperature should not take more than five minutes to heat up. The Director of Nursing (DON) also confirmed that the hot water was taking an unusually long time to reach the appropriate temperature. A review of the facility's policy on safe water temperatures and relevant California Code Regulations further highlighted the deficiency, as the facility failed to maintain hot water temperatures within the required range for resident care areas.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 1,052 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Riverside
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Woodcrest Post Acute & Rehabilitation | 0 mi | ★★★★★ | 15 | 0 |
| Mission Care Center | 0.6 mi | ★★★★★ | 4 | 0 |
| Alta Vista Healthcare & Wellness Centre | 1.2 mi | ★★★★★ | 6 | 0 |
| Villa Health Care Center | 1.3 mi | ★★★★★ | 3 | 0 |
| Valencia Gardens Health Care Center | 1.6 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.