Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
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 Riverside Behavioral Healthcare Center during CMS and state inspections, most recent first.
Improper Quat Sanitizer Testing in Dietary Services: A Dietary Aide and a Cook were observed testing the sanitizing solution by dipping the quat strips longer than the manufacturer's instructions allowed before comparing them to the color chart. Both staff members stated the strips should have been dipped for 1 to 2 seconds and compared within 10 seconds. The DSS also stated that not following the instructions could result in an inaccurate reading.
Therapeutic diets were not followed for three residents ordered low fat/low cholesterol diets. During lunch observation, a Dietary Supervisor saw that each resident was served creamed noodles instead of the parsley noodles listed on the therapeutic menu, despite physician orders for low fat/low cholesterol diets and diagnoses including hyperlipidemia. The RD stated dietary staff should follow physician-ordered therapeutic diets.
Failure to consistently monitor and document the highest pain level for a resident receiving PRN pain medication. A resident with schizoaffective disorder and GERD had an order for Tylenol and pain monitoring every shift, but the MAR showed pain scores documented at medication administration while the shift’s highest pain level was recorded as 0 on multiple occasions. Weekly nursing notes did not reflect the pain documented on the MAR, and no pain care plan was developed despite repeated PRN use.
A resident with schizophrenia was not monitored or documented every 15 minutes as ordered by a physician after a change from 1:1 supervision. Staff interviews revealed that some were not informed of the monitoring change, and required documentation was missing for several hours, contrary to facility policy.
The facility failed to maintain a sanitary environment and adhere to food service safety standards. A preparation sink lacked an air gap, risking water contamination. Storage shelves had chipped paint, and drying racks were grimy, posing cross-contamination risks. An unlabeled cooking oil and cutting boards with indentations were found, potentially leading to foodborne illness. Dust on storage shelves further risked contamination.
The facility failed to ensure dietary staff followed proper food safety procedures, including checking cooking temperatures and correctly testing sanitizer concentrations. Staff did not adhere to cleaning protocols for food preparation surfaces, risking cross-contamination and foodborne illness. The Registered Dietitian confirmed the importance of these practices for resident safety.
The facility failed to clean four pill cutters before storing them in medication carts, as observed by surveyors. Two pill cutters at nursing station 2 had grime and residue, while two at station 1 had powder residue. Staff acknowledged the issue, noting the risk of cross-contamination. Facility policies require clean equipment to prevent infection.
A facility failed to report an altercation between two residents, both with schizoaffective disorder, to the CDPH within the required two-hour timeframe. The incident involved one resident biting another over a dispute about a radio and batteries. Staff witnessed the event, but the report was delayed due to it occurring over the weekend, contrary to facility policy.
A resident with schizophrenia was downgraded from 1:1 monitoring to behavior watch every 15 minutes without a documented assessment. Facility staff, including the DON and an LVN, confirmed that the required assessment and documentation were not completed, contrary to facility policy. This oversight resulted in a gap in the continuity of care.
A resident with schizophrenia was involved in a physical altercation with a Program Counselor, resulting in scratches and redness on the resident's face. The incident occurred when the resident, upset, entered the counselor's office and began swinging her hands. Staff intervened to separate them, but the facility's protocol for de-escalating such situations was not followed, as noted by the DON. The facility's abuse prevention policy requires staff training on handling aggressive behavior, which was not effectively implemented.
A facility failed to provide a safe environment when a resident with schizoaffective disorder alleged abuse by another resident whose room was directly across from his. Despite the resident's history of delusional statements and verbal aggression, staff did not relocate him, leading to continued distress. Interviews revealed a lack of communication and oversight regarding room assignments.
Improper Quat Sanitizer Testing in Dietary Services
Penalty
Summary
The facility failed to ensure dietary staff followed the manufacturer's instructions for testing the quaternary sanitizer. During an observation on November 4, 2025, a Dietary Aide was seen dipping the quat strip into the sanitizing solution for six seconds before comparing it to the color comparator chart. In a concurrent interview, the Dietary Aide stated the manufacturer's instructions required the strip to be dipped for one to two seconds and then compared to the comparator chart within 10 seconds, and stated she should have followed the instruction. Later that same day, the Cook was observed testing the sanitizing solution and was seen dipping the quaternary test strip into the solution for ten seconds before comparing it to the color comparator chart. In a concurrent interview, the Cook stated the instructions required the strip to be dipped for one to two seconds and compared within 10 seconds, and stated she should have followed the instruction. On November 6, 2025, the Dietary Service Supervisor stated that when the chemical sanitizer was not tested according to the manufacturer's instruction, the reading would be inaccurate and had the potential to lead to cross-contamination. The facility's in-service and the testing strip manufacturer's instructions both indicated the strip should be dipped for 1 to 2 seconds and compared to the color chart within 10 seconds.
Therapeutic diets not followed for residents ordered low fat/low cholesterol diets
Penalty
Summary
The facility failed to ensure physician-ordered therapeutic diets were followed for three residents who were ordered low fat/low cholesterol diets. During lunch observation, Resident 65 was served creamed noodles instead of the parsley noodles listed on the therapeutic menu, and the Dietary Supervisor stated the resident should have received parsley noodles. Resident 65’s record showed diagnoses including hyperlipidemia and a physician’s order for a low fat/low cholesterol diet. Resident 53 was also observed being served creamed noodles instead of parsley noodles, and the Dietary Supervisor stated this resident had an order for a low cholesterol, low fat diet. Resident 53’s record also included hyperlipidemia and a physician’s order for a low fat/low cholesterol diet. Resident 32 was observed being served creamed noodles, and the Dietary Supervisor stated this resident should have received parsley noodles consistent with the low cholesterol, low fat diet. Resident 32’s record included hyperlipidemia, and the history and physical stated the resident had the capacity to understand and make decisions. The Registered Dietician stated dietary staff should follow physician-ordered therapeutic diets and that failure to follow a low fat/low cholesterol diet had the potential to increase cholesterol levels for Residents 65, 53, and 32. The facility’s Therapeutic Diets policy stated therapeutic diets are prescribed by the attending physician to support the resident’s treatment and plan of care.
Failure to consistently monitor and document highest pain level
Penalty
Summary
The facility failed to consistently monitor and document the highest level of pain for a resident who was receiving PRN pain medication. Resident 15 was admitted with diagnoses including schizoaffective disorder and gastro-esophageal reflux, and the History and Physical dated July 1, 2025, indicated he had the capacity to understand and make decisions. On October 1, 2025, the resident had a change in condition for sudden lower back pain, and the provider ordered Tylenol 20 ml by mouth every 6 hours for 14 days and to monitor. The resident told the surveyor on November 3, 2025, that he experienced headaches and received pain medication but that it was not provided consistently. The record showed multiple PRN pain medication administrations with documented pain levels of 5, 7, 7, 3, and 4 on October 1, 2, 6, 29, and November 2, 2025. However, the pain monitoring section of the MAR documented the highest pain level for each shift as 0 on those same shifts, including shifts when pain medication had been given for pain above zero. Weekly nursing progress notes for October 29 and November 5, 2025, also did not reflect the pain documented on the MAR. The resident had no care plan developed to address current pain management needs despite multiple documented episodes of pain requiring PRN medication. Staff interviews confirmed that the pain score documented during medication administration should match the shift pain score, and that the highest pain level for the shift was not documented as required by the physician's order.
Failure to Provide and Document Required 15-Minute Monitoring After Change from 1:1 Supervision
Penalty
Summary
The facility failed to provide necessary supervision and monitoring for a resident diagnosed with schizophrenia, as required by physician orders following a change from 1:1 monitoring to every 15-minute checks. Documentation revealed that there was no record of the resident being monitored from 1:30 p.m. to 11:45 p.m. on the specified date, despite the physician's directive and facility policy requiring such monitoring. Multiple staff members, including RNs, LVNs, and CNAs, confirmed during interviews that the monitoring was not documented and, in some cases, staff were not informed of the change in monitoring frequency. The facility's policy stated that staff should assess and observe the resident's behavior and document it every 15 minutes. However, both the monitoring and the required documentation were not completed for a significant period. Staff interviews indicated a lack of communication regarding the change in monitoring status, and the assigned staff did not recall performing or recording the required 15-minute checks. This resulted in a failure to provide the supervision and documentation mandated by the physician's order and facility policy.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a sanitary environment and adhere to professional standards for food service safety. A two-compartment preparation sink used for preparing foods lacked an air gap, which is necessary to prevent the backflow of contaminated water. The Dietetic Services Supervisor (DSS) acknowledged the absence of an air gap, and the Registered Dietitian (RD) was unaware of the regulation requiring it. This oversight could potentially lead to contamination of the water supply and foodborne illness among residents. Additionally, six white storage shelves in a reach-in refrigerator were found with chipped paint, exposing brown metal, which could lead to metal corrosion and contamination of kitchenware or food. The DSS and RD both confirmed that the shelves were worn out and should be replaced to prevent cross-contamination. Furthermore, three drying rack shelves were observed with brown grime, and the DSS verified that these shelves were worn out, posing a risk of cross-contamination to kitchen equipment. Other deficiencies included an unlabeled cooking oil stored in a water pitcher, which the DSS and a cook acknowledged should have been labeled to prevent the use of expired ingredients. Two cutting boards with deep indentations were found, which could harbor microorganisms and cause foodborne illness. Dust was also found on storage shelves inside the dietary storage room and on drying racks, which the DSS and RD confirmed should be cleaned to prevent contamination. These failures collectively posed a risk of foodborne illness to the residents.
Deficiencies in Dietary Staff Practices and Food Safety Procedures
Penalty
Summary
The facility failed to ensure that dietary staff were able to carry out the functions of food and nutrition services safely and effectively. During lunch meal preparation, a cook did not check the cooking temperatures of beef patties, fish, and chicken tenders, which is a standard practice to ensure food safety. The cook admitted to forgetting to check the temperatures and acknowledged the importance of this step in preventing foodborne illness. The Registered Dietitian confirmed that checking the temperature of meat is essential to ensure it is cooked thoroughly and safely. Additionally, dietary staff did not follow the manufacturer's guidelines for testing the concentration of the Quaternary Ammonium sanitizer used for sanitizing food contact surfaces. Multiple staff members demonstrated incorrect procedures for testing the sanitizer, either by not immersing the test strip for the required time or by misinterpreting the concentration levels. The Registered Dietitian emphasized the importance of following the manufacturer's instructions to prevent cross-contamination and foodborne illness. Furthermore, the facility's dietary staff did not adhere to proper cleaning and sanitizing procedures for food preparation surfaces and stationary equipment. Staff members used incorrect methods for cleaning, such as not rinsing between washing and sanitizing steps. The Registered Dietitian outlined the correct procedure, which involves washing with soap and water, rinsing, and then sanitizing. Failure to follow these steps could lead to cross-contamination and potential foodborne illness for residents.
Failure to Clean Pill Cutters in Medication Carts
Penalty
Summary
The facility failed to ensure that four pill cutters used for medication administration were cleaned before being stored in the medication carts. During an observation of the PM medication cart at nursing station 2, two blue pill cutters were found with green-brown grime buildup and white powder residue. The Licensed Psychiatric Technician (LPT) acknowledged that the pill cutters were dirty and should have been cleaned between uses or replaced when dirty. The LPT was unable to confirm when the pill cutters were last cleaned, indicating a lapse in maintaining clean equipment, which could lead to cross-contamination of medications. Further observations at nursing station 1 revealed two additional blue pill cutters with white powder residue on both the AM and PM medication carts. The Assistant Director of Nursing (ADON) confirmed that these pill cutters were also dirty and should have been cleaned or discarded to prevent cross-contamination. The Infection Preventionist (IP) reiterated that medication carts should only contain clean equipment, and any dirty equipment should be discarded to prevent infection. The facility's policies on medication administration and infection control emphasize the importance of maintaining clean and orderly equipment to prevent disease transmission.
Failure to Timely Report Resident Altercation
Penalty
Summary
The facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) within the required timeframe of two hours after the incident was reported. This deficiency involved two residents, both diagnosed with schizoaffective disorder. On November 2, 2024, Resident 80 asked Resident 12 to return a radio and batteries that had been loaned. When Resident 12 refused, Resident 80 attempted to retrieve the items, leading to Resident 12 biting Resident 80 on the hand. The incident was witnessed by staff, but the report to CDPH was delayed because it occurred over the weekend. Interviews with facility staff, including the Assistant Activities Director, Registered Nurse, Administrator, and Director of Nursing, confirmed the incident and the failure to report it promptly. The facility's policy requires that such incidents be reported to CDPH, the LTC Ombudsman, and law enforcement within two hours, with a faxed report preferably by the end of the shift and no later than 24 hours. The delay in reporting this incident had the potential to delay the implementation of protective measures for the residents involved.
Failure to Document Resident Assessment Leads to Inappropriate Monitoring Downgrade
Penalty
Summary
Facility staff failed to document a resident assessment, which led to the inappropriate downgrading of monitoring for a resident diagnosed with schizophrenia. The resident, who was initially placed on 1:1 monitoring following a physical altercation with a peer, was downgraded to behavior watch every 15 minutes without a documented behavioral assessment. This lack of documentation did not accurately reflect the resident's current condition or provide a rationale for the change in monitoring level. Interviews with facility staff, including the Program Manager, Director of Nursing, and a Licensed Vocational Nurse, confirmed that the required assessment and documentation were not completed. The facility's policy mandates that a behavioral assessment and corresponding documentation are necessary before altering a resident's monitoring status. However, the Licensed Vocational Nurse responsible for the assessment admitted to forgetting to document it, resulting in a gap in the continuity of care for the resident.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, resulting in the resident sustaining superficial scratches on both cheeks and redness on the forehead. The incident involved a physical altercation between the resident, who has a diagnosis of schizophrenia and adjustment disorder, and a Program Counselor (PC 1). The altercation occurred when the resident, appearing upset, entered PC 1's office and began swinging her hands. A Certified Nursing Assistant (CNA 1) witnessed the altercation and intervened, along with a Registered Nurse (RN 1), to separate the resident and PC 1. Interviews with staff revealed that the facility's protocol for handling such situations was not followed. The Director of Nursing (DON) stated that all staff are required to undergo Professional Assault Crisis Training (Pro-Act) every two years, which prepares them to deal with assaultive residents. The DON emphasized that staff should de-escalate situations and not harm residents, and that PC 1 did not adhere to these protocols. The facility's policy on abuse prevention mandates staff training on handling aggressive resident behavior, which was not effectively implemented in this case.
Failure to Provide Safe Environment for Residents
Penalty
Summary
The facility failed to provide a safe environment for two residents when one resident, diagnosed with schizoaffective disorder, alleged abuse by another resident whose room was directly across from his. Despite the resident's history of delusional statements and verbal aggression, the facility did not take immediate action to separate the two residents. The resident had expressed agitation and made allegations against the other resident, which were not addressed by relocating him to a different room. Interviews with facility staff revealed a lack of communication and oversight regarding the room assignments. The Program Manager and Program Counselor were aware of the resident's fixation and allegations but did not ensure a room change occurred. The Assistant Director of Nursing acknowledged that moving the resident would have been a preventive measure against further allegations or distress. This oversight resulted in a continued environment of potential distress for both residents involved.
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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.
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Nursing homes near Riverside
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Community Care On Palm | 0.2 mi | ★★★★★ | 15 | 0 |
| The Grove Care And Wellness | 1.2 mi | ★★★★★ | 2 | 0 |
| Community Care And Rehabilitation Center | 1.3 mi | ★★★★★ | 4 | 0 |
| Valencia Gardens Health Care Center | 2 mi | ★★★★★ | 0 | 0 |
| Vista Pacifica Center | 2.6 mi | ★★★★★ | 0 | 0 |
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