Riverside Postacute Care: Fall Sitter Cancelled, Resident Fell - CA
The May inspection at Riverside Postacute Care, an 8781 Lakeview Avenue skilled nursing facility, documented what happened to Resident 2 across a single, disastrous night shift.
On May 13, 2026, at 12:50 p.m., a CNA found Resident 2 on the floor of his room. The charge nurse on duty, LVN 1, told inspectors the CNA had just placed the resident in his wheelchair and stepped out. When the CNA came back, he was on the floor. The facility responded by moving him to a room closer to the nurses' station. The RN on duty, identified in the report as RN 2, called the attending physician and got an order for a 1:1 sitter, someone assigned to watch only him. The sitter was started right away.
RN 2 later told inspectors she had obtained the order because Resident 2 posed an unusual danger to himself. Even in a wheelchair, even in a low bed, he was still able to get himself onto the floor.
That night, someone cancelled the sitter.
The Staffing Coordinator told inspectors that a CNA had been assigned to sit with Resident 2 for the night shift of May 13, but the assignment was cancelled because the facility determined it was overstaffed. The plan instead was for CNAs to take turns checking on him every 30 minutes.
At 1:20 a.m. on May 14, Resident 2 was found on his floor mat. He had a skin tear on his left elbow. The physician and family were notified. Treatment was provided.
RN 2 said that during the morning shift on May 14, the Director of Nursing asked her to call the doctor and have the 1:1 sitter order discontinued. She did. The order was cancelled.
The Director of Nursing, in her own interview with inspectors on May 27, confirmed that the sitter had been removed on May 14 and replaced with the rotating 30-minute check system. Then she said something that undercut the facility's entire account. She told inspectors that Resident 2 should have had a sitter on the night shift of May 13, as ordered.
The DON's admission was unambiguous. The order existed. The need was real. The sitter was cancelled anyway.
What the inspection record shows is a chain of decisions that moved in one direction: away from the level of supervision a physician had determined this resident required. A doctor saw the risk and ordered a fix. A staffing coordinator cancelled it. A director of nursing then had the order itself eliminated the following morning.
The 30-minute rotating check is not a 1:1 sitter. A 1:1 sitter does not leave the room. A rotating check means the resident is alone for stretches of time. For a man who, as RN 2 described him, could get himself onto the floor from a wheelchair or a low bed, 30 minutes of unsupervised time was the gap in which the fall occurred.
The facility's own fall prevention policy, dated December 2016, states that staff will work with the attending physician to identify interventions to reduce fall risk. Its supervision policy, from January 2018, calls for communicating specific interventions to all relevant staff, assigning responsibility for carrying out those interventions, and ensuring they are implemented correctly and consistently.
The physician's intervention was a 1:1 sitter. It was not implemented.
Resident 2 had already fallen once before May 13. He fell again the night the sitter was cancelled. He was on a floor mat with a torn elbow at 1:20 in the morning, and the order that was supposed to keep him safe had been overridden before anyone even knew he'd gone down.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Riverside Postacute Care from 2026-05-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 17, 2026 · Our methodology
RIVERSIDE POSTACUTE CARE in RIVERSIDE, CA was cited for violations during a health inspection on May 27, 2026.
On May 13, 2026, at 12:50 p.m., a CNA found Resident 2 on the floor of his room.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.