Riverside Behavioral Healthcare Center
Inspection Findings
F-Tag F0684
F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
at 1:25 p.m., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated
she was aware of the fall for Resident 1 and that he was hospitalized and did not return to the facility after
the physician identified a right hip fracture. A concurrent review of Resident 1's record was conducted with
the ADON, and she stated the following: a. The physical condition weekly assessments indicated Resident 1 had a fall that occurred on June 6, 2025, and that the weekly assessment for June 11, 2025, did not reflect the acute change that occurred; b. Further reviews of records from June 18, 2025, to July 7, 2025, indicated Resident 1 went from independent with mobility to dependent needing a wheelchair. The ADON stated a COC should have been made on July 2, 2025, when the nurse provided a wheelchair for Resident 1 and there was no change of condition conducted. The ADON stated a change in mobility should be a change in condition and the MD should have been made aware; and c. A care plan regarding a change in physical mobility should reflect the current status of the resident's pain and mobility. On August 19, 2025, at 3:05 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated Resident 1 was
on monitoring for pain and a post fall review indicated Resident 1 was monitored for 72 hours post fall as indicated by the fall protocols. A concurrent record review was conducted with the DON. The DON verbalized that from June 25, 2025, to July 2, 2025, Resident 1 was noted to have made a request for a wheelchair because his mobility status had changed as he requested to use a wheelchair to mobilize because he was afraid to fall again. The DON reviewed June 18, 2025, and June 11, 2025, weekly notes and verbalized Resident 1 did not need to use a wheelchair and was independent with mobility. The DON was asked to define a change of condition based on this finding. The DON stated we did not consider this a change of condition because it was related to his fall on June 6, 2025 and that this was a behavior as it was not that he could not walk but rather he chose not too because of the reasons we are not sure but he was walking before and he was known to have similar behaviors like low participation and refusal of medications. A review of the facility policy and procedure titled, Pain Assessment and Management dated October 2022, indicated, .identify pain in the resident, and to develop interventions that are consistent with
the resident's goals and needs and that address the underlying causes of pain.appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan and the resident's choices related to pain management.recognizing the presence of the pain.addressing the underlying causes of the pain.observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain.negative verbalizations.changes in gait, behavior such as resisting care.decreased participation in usual physical and/or social activities.identifying cause of pain.fractures.pain management interventions shall address the underlying causes of the resident's pain. A
review of the policy and procedure titled, Change in a Resident's Condition or Status dated May 2017, indicated, .significant change in the resident's physical/emotional/mental condition.refusal of treatment or medications two (2) or more consecutive times.significant change of condition is a major decline or improvement in the resident's status that.will not normally resolve itself without intervention by staff or by implementing standard interventions.impacts more than one area of the resident's health status.
Event ID:
Facility ID:
05A263
If continuation sheet
RIVERSIDE BEHAVIORAL HEALTHCARE CENTER in RIVERSIDE, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in RIVERSIDE, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from RIVERSIDE BEHAVIORAL HEALTHCARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.