Above average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Heights Healthcare Center, Llc during CMS and state inspections, most recent first.
A resident receiving Risperdal for schizophrenia and depression was repeatedly observed with a facial chewing motion, a sign of extrapyramidal symptoms (EPS). Despite ongoing EPS monitoring and an AIMS assessment indicating no abnormal movements, staff failed to recognize or document the symptom. Both a CNA and an LVN observed the motion but did not identify it as EPS, and the DON later confirmed the symptom as EPS, noting that nursing should have recognized it.
A resident with chronic respiratory failure and other complex conditions was not provided with oxygen as ordered by the physician when their oxygen saturation dropped below the specified threshold. The resident was found in a common area without oxygen, displaying restlessness and an oxygen saturation of 80%, and no portable oxygen was available. Both an LVN and the DON confirmed that the physician's order was not followed, and facility policy for oxygen therapy was not adhered to.
A resident with multiple cardiac conditions received an antihypertensive medication on four occasions when their systolic blood pressure was below the physician-ordered hold parameter. Nursing staff did not follow the prescribed BP threshold for holding the medication, as confirmed by the DON and documented in the MAR.
A medication error rate of 8% was observed when an LVN failed to follow manufacturer instructions for administering prefilled insulin pens to two residents with diabetes. The LVN did not hold the dose knob in place for the required 5 seconds after injection, as confirmed by the DON and the facility's policy, resulting in improper administration of prescribed insulin doses.
A medication refrigerator containing vaccines, insulin, and other injectables was repeatedly found to be stored below the required temperature range, with logs showing frequent readings under 36°F and occasional missing documentation. Nursing staff and the DON confirmed that temperatures were not consistently maintained or documented as required by both manufacturer instructions and facility policy.
Kitchen staff used expired chlorine test strips to test the sanitizing solution in the dishwashing machine. Both dietary staff and the RD confirmed that expired strips should not have been used, as this prevented accurate verification of sanitizer concentration, contrary to facility policy.
Nursing staff did not consistently follow infection control protocols for oxygen therapy and glucometer disinfection. A resident's oxygen cannula was not changed or stored according to policy, and two residents had their blood glucose checked with a shared glucometer that was not disinfected per manufacturer instructions. Staff interviews revealed a lack of understanding of required procedures, and facility policies were not followed, increasing the risk of cross-contamination.
The facility failed to adhere to its policies for oxygen therapy for two residents with COPD. One resident's oxygen saturation was documented only once per day instead of every shift, and another resident's oxygen levels were not monitored every shift as ordered. The facility's administrator confirmed that staff should document oxygen levels per physician orders.
A resident with multiple pressure ulcers was found with a tightly fitted sheet over their low air loss mattress, contrary to best practices and facility training. Staff interviews confirmed that fitted sheets should not be used on these mattresses, and the presence of the fitted sheet was a mistake.
The facility failed to conduct outbreak testing as directed by the CDC when a resident tested positive for COVID-19. Despite having policies in place, the facility tested residents and staff weekly instead of following the CDC's recommended testing schedule. The resident involved had severe cognitive impairment and multiple active diagnoses.
Failure to Identify and Respond to EPS in Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to identify and respond to adverse effects of psychotropic medication in one resident who was administered Risperdal, an antipsychotic medication. The resident, who had diagnoses including schizophrenia and depression, was observed on two separate occasions exhibiting a facial chewing motion while in the dining room. Despite these visible symptoms, the resident's medical record indicated that EPS (extrapyramidal symptoms) monitoring was documented as negative for all shifts during the same period, and an AIMS assessment earlier in the month also reported no abnormal involuntary movements. Interviews with the assigned CNA and LVN confirmed that both observed the facial chewing motion but were unaware that it was a sign of EPS. The DON also observed the symptom and identified it as EPS, stating that nursing staff should have been able to assess these signs and symptoms. The facility's policy required documentation of adverse reactions and monitoring for psychotropic drug complications, but this was not effectively implemented for this resident.
Failure to Follow Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to provide appropriate respiratory care and treatment for a resident with chronic respiratory failure and other significant diagnoses, including Huntington's disease, dementia, and a history of seizures. The physician's order specified that oxygen should be administered at 2-3 liters per minute via nasal cannula or face mask if the resident's oxygen saturation fell below 92%. On one occasion, the resident was observed in his room receiving oxygen at the prescribed rate. However, on another occasion, the resident was found in the activity room without oxygen, appeared restless, and had an oxygen saturation of 80%. No portable oxygen tank was available at that time. When the low oxygen saturation was identified, an LVN confirmed that the resident should have been on oxygen per the physician's order and returned the resident to his room to administer oxygen. The DON also acknowledged that the resident should have been on oxygen in the activity room to maintain the required oxygen saturation. The facility's policy on oxygen therapy requires that oxygen be administered as ordered by the physician and that residents be monitored for signs of oxygen deprivation, but these procedures were not followed in this instance.
Failure to Follow Blood Pressure Parameters for Antihypertensive Medication Administration
Penalty
Summary
Nursing staff failed to follow physician-ordered blood pressure (BP) parameters for the administration of metoprolol succinate ER in one resident with a history of hypertension, heart failure, cardiomyopathy, and atrial fibrillation. The resident's care plan specifically indicated the need to hold the antihypertensive medication if the systolic BP (SBP) was below 110 mmHg. Despite this, the medication was administered on four separate occasions in April 2025 when the resident's SBP was below the prescribed threshold, as documented in the Medication Administration Record (MAR). The Director of Nursing (DON) confirmed during interviews and record reviews that the medication should not have been given under these circumstances and acknowledged that staff did not adhere to the hold parameters. Facility policy also required nurses to follow precautionary instructions on prescription labels, including parameters. Manufacturer's prescribing information for metoprolol succinate ER lists hypotension as a common adverse reaction, further underscoring the importance of following such parameters.
Medication Error Rate Exceeds 5% Due to Improper Insulin Pen Administration
Penalty
Summary
A medication error rate of 8% was identified during a medication administration observation, with two errors occurring out of 25 opportunities. The errors involved a licensed vocational nurse (LVN) administering prefilled insulin pens (Humalog and Lispro) to two residents with diabetes. In both cases, the LVN failed to hold the dose knob of the insulin pen in place for at least 5 seconds after injection, as required by the manufacturer's instructions. Instead, the LVN pressed and immediately released the dose knob, which could have resulted in the residents not receiving the full prescribed dose of insulin. The medical records for both residents showed active physician orders for subcutaneous insulin administration before meals. During interviews, the LVN acknowledged not being aware of the requirement to hold the dose knob for 5 seconds. The Director of Nursing (DON) confirmed, after reviewing the manufacturer's instructions, that the correct procedure was not followed during the observed medication passes. The facility's policy on subcutaneous medication administration also indicated that medication should be injected slowly.
Failure to Maintain Proper Medication Refrigerator Temperatures
Penalty
Summary
The facility failed to ensure that refrigerated medications and biologicals were stored at temperatures in accordance with both facility policy and manufacturer specifications. During an observation at a nursing station, a medication refrigerator was found to contain various medications, including vaccines, insulin, and other injectables, which require storage between 36°F and 46°F. Review of the refrigerator temperature logs from January to June 2025 revealed multiple instances where the temperature fell below the required range, with readings as low as 25°F on one occasion and frequent readings of 34°F and 35°F on numerous days and shifts. Nursing staff and the DON confirmed that the expected practice was to monitor and document refrigerator temperatures at the start of each shift and to take corrective action if temperatures were out of range. Interviews with nursing staff indicated that when the refrigerator temperature was found to be out of range, staff were expected to adjust the thermostat and recheck the temperature after a short interval. If the temperature did not return to the acceptable range, maintenance was to be notified. However, the logs showed repeated failures to maintain the correct temperature, and there were also instances of missing temperature documentation. The DON acknowledged these lapses and confirmed that the facility's policy required strict adherence to temperature monitoring and documentation protocols. Manufacturer instructions for all medications stored in the refrigerator, including Afluria, Latanoprost, Ozempic, Retacrit, Semglee, and Tubersol PPD, specified storage within the 36°F to 46°F range. The facility's own policy also required medications needing refrigeration to be kept within this range. The repeated failure to maintain proper storage temperatures and to consistently document temperature readings constituted a deficiency in the facility's medication management practices.
Expired Chlorine Test Strips Used for Dishwasher Sanitization
Penalty
Summary
The facility failed to ensure safe storage, preparation, and distribution of food when kitchen staff used expired chlorine test strips to check the sanitizing solution in the dishwashing machine. During an observation, a dietary aide was seen using test strips that had expired on May 1, 2025, to test the dishwasher's chlorine level. Both the dietary aide and the dietary supervisor confirmed that the test strips were expired and should not have been used. The registered dietician also stated that expired test strips would prevent staff from accurately determining if the sanitizing solution was at the correct concentration. The facility's policy required the use of manufacturer-recommended test strips to verify appropriate sanitizing levels.
Failure to Follow Infection Control Protocols for Oxygen Therapy and Glucometer Disinfection
Penalty
Summary
Nursing staff failed to implement proper infection prevention and control practices for three residents. For one resident receiving oxygen therapy, the nasal cannula was not changed every seven days as required by both physician order and facility policy. The cannula in use was labeled with another resident's name and an outdated date, and an additional cannula attached to a portable oxygen tank was not dated or stored in a plastic bag, leaving it exposed to the environment. Staff interviews confirmed uncertainty about the required frequency for changing the cannula and improper storage practices, despite clear facility policies mandating weekly changes, labeling, and sanitary storage. Additionally, two residents who required blood glucose monitoring were exposed to improper disinfection practices with a shared glucometer. A nurse was observed wiping the glucometer with a Sani-Cloth disposable wipe but did not adhere to the manufacturer's specified contact time, which requires the surface to remain wet for two minutes to ensure effective disinfection. The nurse was unaware of the meaning of 'contact time' and did not follow the instructions on the wipe label. The infection preventionist and DON both acknowledged that staff were expected to follow the manufacturer's instructions for disinfection but confirmed that the observed practice did not meet these requirements. Facility policy for both oxygen therapy and blood glucose monitoring clearly outlined the necessary infection control steps, including equipment change intervals, labeling, storage, and disinfection procedures. However, observations and staff interviews revealed that these protocols were not consistently followed, resulting in a failure to prevent potential cross-contamination and infection among the affected residents.
Failure to Monitor Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to provide respiratory care and treatment in accordance with its policies and procedures for two residents who were receiving oxygen therapy. Resident 1, who has a medical history of chronic obstructive pulmonary disease (COPD), anxiety disorder, and paranoid schizophrenia, was ordered to receive continuous oxygen at 2-3 liters per minute via nasal cannula or face mask for oxygen saturation below 92%. The physician's orders specified that oxygen saturation should be documented every shift, especially if oxygen is delivered at 3 liters per minute or above, requiring a humidifier. However, the facility only documented Resident 1's oxygen saturation once per day instead of every shift as ordered. Resident 4, who has COPD exacerbation, status asthmaticus, depression, anxiety, and periodic psychosis, was also not monitored according to the physician's orders. The orders indicated that oxygen should be used at 2-3 liters per minute for oxygen saturation below 88%, with monitoring every shift. If oxygen is delivered at 3 liters per minute or above, a humidifier must be applied. Despite these orders, the facility only documented Resident 4's oxygen saturation on specific days, failing to monitor it every shift as required. During interviews, the facility's administrator acknowledged that staff should be documenting oxygen levels per physician orders. The facility's policy on oxygen therapy, revised in November 2017, requires documentation of administration in the medication administration record and oxygen saturation levels per physician order. The lack of adherence to these policies and procedures resulted in the potential for ineffective oxygen therapy and respiratory distress for the residents involved.
Improper Use of Low Air Loss Mattress for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to ensure proper use of a low air loss mattress for a resident with multiple pressure ulcers. Resident #42, who was admitted on 04/08/2020, had diagnoses including pressure-induced deep tissue damage and multiple pressure ulcers. The resident's care plan, revised on 10/16/2023, included the use of a low air loss mattress as an intervention to manage and prevent pressure ulcers. However, during an observation on 04/02/2024, the resident was found with a tightly fitted sheet over the low air loss mattress, contrary to best practices and facility training. Interviews with various staff members, including the Medical Director, Registered Nurse #1, the Director of Staff Development (DSD), and the Director of Nursing, confirmed that fitted sheets should not be used on low air loss mattresses. The DSD stated that staff were trained to use only draw sheets and chux on these mattresses, and the presence of a fitted sheet was a mistake. The Administrator's opinion was noted as irrelevant. The deficiency was further supported by a review of an in-service sign-in sheet dated 08/01/2023, which indicated that staff were instructed on the correct use of low air loss mattresses.
Failure to Conduct Proper Outbreak Testing for COVID-19
Penalty
Summary
The facility failed to conduct outbreak testing as directed by the Centers for Disease Control and Prevention (CDC) when a resident tested positive for COVID-19. The facility's policy on infection prevention and control, as well as specific policies on resident and employee COVID-19 testing, were reviewed and found to be in alignment with CDC guidelines. However, the facility did not follow these guidelines when a resident tested positive for COVID-19. The CDC recommends testing all residents and healthcare personnel identified as close contacts or on the affected units immediately (but not earlier than 24 hours after exposure) and then again at 48-hour intervals if the initial tests are negative. Instead, the facility tested residents and staff weekly, which did not comply with the CDC's recommended testing frequency. Resident #119, who had severe cognitive impairment and multiple active diagnoses, tested positive for COVID-19 on 01/09/2024 after being readmitted to the facility. The Infection Preventionist (IP) and Director of Nursing confirmed that the facility conducted weekly testing for residents and staff on 01/09/2024, 01/16/2024, and 01/23/2024, rather than following the CDC's recommended testing schedule. The Administrator acknowledged that staff were expected to follow regulations, but the facility's actions did not align with the CDC's guidelines for outbreak testing, leading to the identified deficiency.
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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) |
|---|---|---|---|---|
| Riverside Postacute Care | 3.3 mi | — | 93 | 2 |
| Jurupa Hills Post Acute | 3.5 mi | ★★★★★ | 7 | 0 |
| Vista Pacifica Convalescent Hospital | 3.6 mi | ★★★★★ | 0 | 0 |
| Vista Pacifica Center | 3.6 mi | ★★★★★ | 0 | 0 |
| Citrus Nursing Center | 4.7 mi | ★★★★★ | 0 | 0 |
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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.