Extended Care Hospital of Riverside

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an environment free of accident hazards and to ensure resident receives adequate supervision and assistance devices, for three of three residents reviewed for accidents (Residents 34, 85 and 24) when:1. Resident 34 was found to have cigarettes and a lighter at bedside. This failure had the potential to place Resident 34 and other residents at risk for harm and injuries.2. Resident 85 did not receive adequate supervision and effective fall prevention interventions. This failure resulted in Resident 85 sustaining a fall with facial injuries requiring hospital transfer. 3. Resident 24, assistance device (call light) was not within reach. This failure had the potential to result in the resident being unable to request for assistance, placing her at risk for injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Physician orders with parameters were followed when medications were administered without documenting the systolic blood pressure for one of three residents reviewed after medication pass observation. This failure had the potential for residents to inadvertently receive medications when they need to be held according to the physician's orders. 2. medications contained in the medication carts were not discontinued or discharged and not stored in the cart along with active residents' medications. This failure had the potential for discontinued medications to be used as not intended; 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide required information and follow up with the resident's representative (RP) regarding Advance Directives (AD - written statement of a person's wishes regarding medical treatment) for one of one resident reviewed for AD (Resident 6), who lacked decision-making capacity. This failure had the potential to prevent the resident's representative from participating in medical decision-making and ensuring the resident's treatment preferences were honored.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of transfer and failed to provide a written bed-hold notice to one of three residents reviewed for discharges (Resident 111) and or the resident representative at the time of transfer to the hospital. These failures had the potential to deny the resident the right to be informed of transfer and bed-hold rights, including the right to reserve and return to a bed.

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate Pre-admission Screening and Resident Review (PASARR) and referral for one of three residents reviewed for PASARR (Resident 5) when the resident was admitted with documented diagnoses of major depressive disorder and psychosis and was not referred to the State-Designated Authority (SDA) for a PASARR Level II evaluation. This had the potential to prevent a determination of the resident's need for specialized mental health services and prevented incorporation of PASARR recommendations into the resident's comprehensive care plan.

Inspectors wroteBased on interview and record review, the facility failed to monitor and assess an intravenous (IV - intravenous catheter inserted into the vein to deliver fluids and medication) site for one of one resident reviewed for parenteral (administered by injection) fluids (Resident 124) according to facility policy. This failure had the potential to result in undetected IV-related complications including infection, infiltration, or inflammation of a vein.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications that required refrigeration were not stored outside of the refrigerator at room temperature. This failure had the potential for residents to receive ineffective medications. On February 10, 2026, at 12:40 p.m., during an inspection of the medication cart (Cart 1) located at Nursing Station 1, there was an amber bottle containing approximately 80 ml (milliliter, unit of measurement) of gabapentin (medication to treat seizure) 250 mg (milligram, unit of measurement) per 5 ml solution for Resident 55. The gabapentin bottle had an auxiliary label that indicated, Refrigerate. During a concurrent interview, LN 16 confirmed the bottle was stored in Cart 1 at room temperature and stated it should have been in the medication refrigerator. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a diet in accordance with physician's orders for one of 19 residents reviewed during dining observation (Resident 14), when the resident, who had a documented allergy to nuts was served a brownie containing nuts. This failure placed the resident at risk for an allergic reaction.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the physician-ordered therapeutic diet (a diet ordered by a physician as part of resident's medical treatment to manage a disease or condition) was followed for one of 19 residents reviewed for nutrition (Resident 90), when the resident was not provided the ordered minced and moist diet texture at lunch on February 12, 2026. This failure had the potential to result in decreased nutritional intake and increased risk for choking due to the resident's dysphagia (difficulty swallowing).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety requirements for food storage and preparation were followed when one expired 12-ounce Tabasco sauce was found in the dry storage room readily available for use. This failure had the potential to place the residents at risk for food-borne illness in a medically vulnerable population of 82 residents who consumed food prepared by the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an allegation of abuse was reported to the State survey agency within two hours for two of five residents, (Residents 2 and 3). This failure had the potential for a delay in the investigations and interventions to prevent further incidents of abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care and treatment were provided for four of seven residents reviewed (Residents 1, 4, 5, and 6) when:1. For Resident 1, the licensed nurses did not timely assess and monitor the resident who experienced a change in condition on June 16, 2025. This failure resulted in the hospitalization of Resident 1 on June 20, 2025, with a diagnosis of urinary tract infection (an infection that occurs in any part of the urinary system [how the body gets rid of extra water and waste]). 2. For Residents 4, 5, and 6, peripheral intravenous (IV - administration of fluids or medication through the vein) sites were not documented as assessed or changed for the duration of the admission. This failure had the potential to place Residents 4, 5, and 6 at risk for infection and injury due to prolonged use of the same IV access.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the physician was notified of a significant change in condition and refusal of treatment for one of seven sampled residents (Resident 1). This failure had the potential for further confusion, aggressive behaviors, and refusal of care, and led to discomfort with the potential for complications related to untreated infection.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of physical abuse to the California Department of Public Health (CDPH) within two hours after the allegation was made, for one of six sampled residents (Resident A). This failure had the potential to result in psychosocial harm to Resident A and other residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR- a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) Level I screening accurately reflected the presence of diagnosed mental disorders for one of three sampled residents (Resident A). This failure had the potential to result in the inappropriate admission of residents who may not meet the criteria for nursing facility placement, and in the resident not receiving the appropriate services for their diagnosed mental health conditions.

Inspectors wroteBased on interview and record review, the facility failed to ensure a post discharge follow-up was conducted and documented in the medical records for one of three residents reviewed (Resident 1). This failure had the potential to compromise Resident 1's safety and well-being by not ensuring post-discharge needs were met.

Inspectors wroteBased on interview and record review, the facility failed, for one of four residents (Resident 1), to ensure the Office of the State Long-Term Care Ombudsman (LTC Ombudsman - an advocate for residents to protect residents' rights and ensure quality care) received timely notification of Proposed Transfer/Discharge (a planned or suggested move of a resident from a healthcare facility to another location) when Resident 1 was discharged on January 31, 2025. This failure has the potential to result in Resident 1 lacking an advocate to protect their rights and ensure an appropriate and safe discharge plan.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff discussed the decisions and the rationale regarding issues or concerns raised by the Resident Council (a group of residents who come together to discuss concerns, make suggestions, and advocate for improvements in their living environment). This failure had the potential to feel that their voices were not heard which could result in dissatisfaction and a decline in quality of life.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to assess for self-administration of medication for 1 (Resident #93) of 1 sampled resident that expressed a desire to self-administer medications.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to submit a new Preadmission Screening and Resident Review (PASARR) following a newly diagnosed mental disorder for 1 (Resident #45) of 2 sampled residents reviewed for PASARR requirements.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) Level I screening accurately reflected the presence of diagnosed mental disorders for 1 (Resident #23) of 2 sampled residents reviewed for PASARR requirements.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure staff provided needed assistance with activities of daily living (ADLs) for 1 (Resident #85) of 1 sampled resident reviewed for ADLs. Specifically, staff failed to assist Resident #85 with facial hair grooming and nail care.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide tube feeding formula as ordered to 1 (Resident #85) of 3 sampled residents reviewed for nutrition. Specifically, Resident #85's order directed staff to provide Isosource 1.5 (a type of tube feeding formula that provided 1.5 calories per milliliter) to the resident at a rate of 60 milliliters (mL) per hour for 16 hours per day, but staff provided Fibersource HN (a type of tube feeding formula that provided 1.2 calories per mL) instead, which created a potential for weight loss and for the resident's nutritional needs to not be met.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to properly store a nebulizer mask between uses for 1 (Resident #7) of 1 sampled resident reviewed for respiratory care.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure pain was treated after a request for an ordered as needed (PRN) pain medication for 1 (Resident #210) of 1 sampled resident reviewed for pain management.

Inspectors wrote2. An admission Record revealed the facility admitted Resident #5 on 12/14/2023. According to the admission Record, the resident had a medical history that included a diagnosis of colostomy malfunction. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/06/2024, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had an ostomy. Resident #5's care plan included a focus area, initiated 10/08/2024, that indicated the resident was on EBP related to a history of extended-spectrum beta-lactamase (ESBL; a type of enzyme causing some antibiotics to be ineffective in treating bacterial infections). [...]

Inspectors wroteBased on observation, interview, and record review the complaint can be substantiated that the facility failed to ensure the temperature was between 71- and 81-degrees Fahrenheit for 46 of 96 residents. This failure caused residents to be uncomfortable and had a potential for heat related illnesses in a vulnerable population.

Inspectors wroteBased on interview and record review the facility failed to weigh two of three residents reviewed (Resident A and Resident B), on admission and every week for the first four weeks, to establish a baseline weight. In addition, there was no consistent weight changes monitoring conducted for Resident B. These failures had the potential to result in delayed provision of treatment and care in accordance with professional standards of practice, for Residents A and B.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's water temperatures were maintained at a comfortable level for one of three residents reviewed, (Resident 1) when the resident's and/or resident ' s representatives (RR) complained the hot water took too long to heat in their bathrooms. This failure had the potential for Resident 1 to feel uncomfortable and affect their quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure maintenance and repairs were performed timely for three of six residents reviewed (Residents 1, 2, and 3), when: 1. The bathroom wall for Residents 1 and 2, had missing drywall, and the open areas of the wall were observed to have brown and black speckled particles; 2. The wall beside the resident ' s closet for Residents 1 and 2, was missing drywall and the baseboard under the closet was warped; and 3. The bathroom baseboard was lifted and pulling away from the wall, near the toilet for Residents 2 and 3. These failures had the potential to negatively impact the residents ' psychosocial well-being, potentially expose Residents 1 and 2 to mold growth, and had the potential for Resident 2 and 3 to be at risk for skin tears.

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove the indwelling catheter (a tube inserted into the bladder allowing urine to drain freely into a bag outside your body), for one of three sampled resident (Resident A), as ordered by the physician. This failure resulted in the resident having an indwelling catheter without an indication for its use and increasing the risk of having a urinary tract infection (when bacteria gets into the urinary tract [body's drainage system for removing urine].

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when: 1. The ice machine was not cleaned and sanitized properly per manufacturer's guidance; 2. Three various sizes of cooking pans, readily available for use, had a dry and heavy black substance buildup on the cooking surfaces, and 3. Several various size of metal pans were stacked and stored wet. These failures had the potential to cause food-borne illness in a medically vulnerable resident population who consumed food from the kitchen in the facility. The facility census was 79.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menu was followed for the therapeutic diet (a diet that is usually a modification of a regular diet. It is modified or tailored to fit the nutrition needs of a particular person. It could be a part of the treatment of a medical condition and normally prescribed by a physician) during the lunch meal on June 7, 2022, when: 1. 11 residents (Residents 4, 32, 38, 40, 45, 46, 49, 76, 79, 85, and 86) with CCHO (consistent carbohydrate) diet (a diet used in the treatment for diabetes) received one serving of dessert cake instead of a half serving; 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement a policy and procedure on Foods For Residents From Outside Sources that included provisions on facility providing education and information about safe food handling practices to residents, family and visitors, and provisions on facility providing training to all facility personnel regarding safe food handling practices who are involved in preparing, handling, serving, or assisting the resident with meals or snacks. This failure had the potential to cause foodborne illnesses in a medically vulnerable population of 67 out of 79 residents who could consume food and receive food from family or visitors.

Inspectors wroteBased on observation, interview, and record review the facility failed for two residents reviewed to ensure that quality care was provided when: 1. For Resident 73, during medication pass observation, the facility staff failed to do hand hygiene in between picking dropped equipment from the floor and medication preparation. This failure had the potential to cause cross contamination; and 2. For Resident 141, the facility failed to follow doctor's order to perform intake and output monitoring. This failure had the potential to cause fluid overload.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure: 1. One medication, Diabetic Tussin- (used to relieve coughs caused by the common cold, bronchitis, and other breathing illnesses), was stored in the medication cart at station 2, in a drawer without a verified pharmacy label. This failure had the potential for the resident to receive medication without a physician order. 2. The refrigerator temperature in the medication refrigerator at station two was documented at 73 degrees on June 1, 2022, and 48 degrees on June 2, 2022. This failure had the potential for medication to become ineffective and unstable.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the antibiotic prescribed by the physician was adjusted after the culture and sensitivity result (A culture is a test to find germs (such as bacteria or a fungus) that can cause an infection. A sensitivity test checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection) of wound does not show the antibiotic (Vancomycin-is an antibiotic used to treat infections) to be sensitive. This failure had the potential to cause adverse event like antibiotic-resistant organism from inappropriate antibiotic use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, and sanitary environment when one staff member was observed entering and exiting a room in the yellow zone (persons under investigation for COVID-19) without following the proper sanitary precautions, and one staff member did not prevent the potential for cross contamination when a medication tray was placed on the sink in the bathroom while performing hand hygiene. These failures had the potential to result in the development of an unsafe and unsanitary environment to a vulnerable resident population.