Riverside Behavioral Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the dietary staff followed the manufacturer's instructions for testing the Quaternary (quaternary ammonium compounds [quats] are a group of chemicals used as disinfectants) sanitizer. This failure had the potential to result in inaccurate readings of the sanitizing solution, which could lead to cross-contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the physician-ordered therapeutic diets were followed for three of nine residents (Residents 65, 53, and 32). Each of these residents, who were ordered a low cholesterol -low fat diet were served creamy noodles instead of parsley noodles as specified on the therapeutic menu. These failures had the potential to result in increased cholesterol levels and compromised nutritional status for these residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently monitor and document resident's highest level of pain as ordered by the physician, for one of two residents reviewed for pain (Resident 15). This failure had the potential for the resident to experience pain and discomfort, which could negatively impact physical and mental well-being.

Inspectors wroteBased on interview and record review, the facility failed to: a. Evaluate changes in behavior, including refusal to participate in activities, and changes in mobility and function, after a fall incident for Resident 1. This failure could delay pain recognition and intervention, causing the resident to continue experiencing pain. b. Re-evaluate interventions to address continuous complaint of pain by Resident 1. This failure has the potential to result in mobility issues, social isolation, and inability to perform daily activities. c. Promptly arrange an MRI (Magnetic Resonance Imaging- medical imaging technique used in radiology to generate pictures of the anatomy and the physiological processed inside the body) for Resident 1's right hip pain. This failure could have delayed diagnosing a fracture, leading to postponed intervention and increased pain for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure for one of two sampled residents (Resident 1), Resident 1 received necessary supervision and monitoring, as required by the physician for every 15-minute checks following a downgrade from 1:1 monitoring. This failure resulted in lack of observation and documentation and had the potential to result in aggression and harm towards other residents without timely staff intervention.

Inspectors wroteBased on observation, interview, and record reviews, the facility failed to maintain a sanitary environment, prepare, and serve food in accordance with professional standards for food service safety when: 1. The two-compartment preparation sink (sink used for preparing foods) did not have an air gap (a vertical space between the end of a pipe and the top of a nearby sink that prevents the backflow of contaminated water); 2. Six out of six white storage shelves in the reach-in refrigerator labeled number 2, were found to have peeled chipped paint. 3. Three drying rack shelves (one near the handwashing sink and two by the side doorway kitchen entrance) were found to be worn and with brown grime. 4. One unlabeled cooking oil was stored in a water pitcher found in the kitchen; 5. Two cutting boards with deep indentations were found in the kitchen; and 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dietary staff were able to carry out the functions of food and nutrition services safely and effectively when: 1. [NAME] 1 (CK) 1 did not check the cooking temperature for beef patties, fish, and chicken tenders during lunch meal preparation on November 5, 2024; 2. Dietary staff did not follow manufacturer's guidelines for testing the red bucket sanitizer; 3. Four dietary staff did not follow the facility food preparation and cleaning procedure of surfaces and stationary equipment; 4. One Dietary Aide did not know the right concentration of the red bucket sanitize; and 5. One Dietary Aide did not know the right location and could not demonstrate the correct procedure to test for dish sanitization. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four pill cutters (equipment used to cut medications) were cleaned before being stored in the medication carts (equipment used to store and dispense medications). This failure had the potential to result in cross contamination (transfer of microorganism (germs) from one object to another) of medications which could lead to infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of abuse was reported to the California Department of Public Health (CDPH) immediately, and no later than two hours after the allegation was made, for two of five residents reviewed for abuse (Residents 12 and 80). This failure had the potential to delay the implementation of appropriate action and protective measures for the residents, placing them at risk for further abuse.

Inspectors wroteBased on interview and record review, facility staff failed to document a resident assessment, leading to the downgrading of monitoring (decreasing level of monitoring resident by staff) from 1:1 (one staff member monitors one resident) to behavior watch every 15 minutes, for one of 10 sampled residents (Resident 1). This failure had the potential to not accurately reflect the resident's current condition and the rationale for downgrading their monitoring level, leading to a gap in the continuity of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of the three sampled residents (Resident 10) was free from physical abuse when a Program Counselor (PC 1) had a physical altercation with Resident 10. This failure resulted in Resident 10's sustaining superficial scratches on both cheeks and redness on the forehead.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe resident environment for two of three sampled residents (Residents 1 and 2), when Resident 1's room remained across from Resident 2 who Resident 1 had alleged abused him. This failure had the potential to result in increased mental anguish and/or emotional distress for both Resident 1 and Resident 2, who was falsely accused.

Inspectors wroteBased on interview and record review, the facility failed to ensure for one of three residents (Resident B), received monitoring every 15 minutes as indicated for behavior watch. This resulted in Resident B, visiting Resident A, which led to an allegation of sexual abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. A physician was screened for COVID-19 (Coronavirus - a respiratory disease caused by a virus which mainly spreads from person to person) signs and symptoms prior to entering the facility.; This failure increased the risk of spread of infection to residents and staff. 2. A staff was observed licking his fingers in between serving the puddings to the residents in the dining room. This failure has the potential to result in transmission of infectious illnesses to the residents. 3. An annual respirator fit-testing for the staff was completed; and This failure increased the risk that staff's respirator fit had changed resulting in ineffective respiratory protection. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the physician was notified of the elevated blood sugar, in accordance with the physician order, for one of 24 residents reviewed (Resident 270). This failure had the potential to result for the physician to not be aware of the residents' medical condition, delaying treatment and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents were provided with a clean, safe, comfortable environment when: 1. The broken cabinet used for book storage in the dining room, was not reported to the maintenance staff, in accordance to the facility policy and procedure. This failure resulted for the cabinet to remain broken, placing the residents in an unsafe environment. 2. A resident's broken bed frame was left unfixed, and still being used. This failure had the potential for the resident to be at risk for experiencing irregular and uncomfortable sleep, subject to injury, and compromise the integrity of his clothing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a care plan was initiated to address a resident's dental problem during the comprehensive assessment for one of 24 residents reviewed (Resident 25). This failure had the potential to not be able to address the resident's medical, physical, mental, and psychosocial needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide prompting and cueing during performance of Activities of Daily living (ADL) for one of one resident reviewed for ADL (Resident 52). This failure would not enhance the resident's quality of life as it diminishes the resident's self-esteem and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident's preference for reading materials were provided for one of one resident reviewed for activities (Resident 80). This failure had the potential for the resident to not be able to attain pleasure and comfort while staying in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of the 24 residents reviewed for quality of care (Resident 89), was assessed and monitored when the resident developed rashes on his feet. This failure had the potential to result in the delay in the treatment which could affect the resident's physical, psychosocial, and mental well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an expired medication was discarded and not stored to be available for use. This failure had the potential to result in giving a medication that was less effective and causing serious health risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's food were stored in a manner to prevent contamination when a box of corn bread mix was left open and unsealed. This failure increased the potential for food to be contaminated and cause food-borne illness to the residents of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility equipment (dyer) was in safe operationg condition, when the dryer lint trap was observed to be covered with thich white lint. This failure had the potential to result in fire hazards.