Riverside Postacute Care
Inspection Findings
F-Tag F0656
F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Based on interview and record review, the facility failed to develop and revise a comprehensive, person-centered care plan to address transportation needs for one of three sampled residents (Resident 1) reviewed for dialysis. The facility did not complete an interdisciplinary assessment or care plan update when
it changed the resident's transportation method for dialysis from a wheelchair-accessible van to a standard vehicle (Uber). As a result, the resident was transported in an inappropriate vehicle that did not accommodate her functional limitations, leading to missed dialysis treatments, hospitalization, and physical injury.Findings:On October 3, 2025, at 1:08 p.m., during an interview, the SSD stated dialysis residents are admitted to the facility with transportation and dialysis appointments already arranged and that she arranged transportation for any make up dialysis days. The SSD stated Resident 1's insurance is accepted by very few transportation companies. The SSD stated they were using a private wheelchair van transportation for Resident 1, but the facility stopped paying and she does not know why. The owner of the private wheelchair van transportation informed her that because he was not getting paid, he could not take Resident 1 to dialysis anymore. The SSD stated the Case Manager (CM) arranged recurrent trips for Resident 1's dialysis appointments via Uber which started the week of September 22, 2025. The SSD stated this was not discussed with Resident 1 nor her family member (FM). The SSD stated it was the corporate office who determined to use Uber because they did not want to pay for wheelchair van transportation. The SSD stated if the resident's insurance does not cover transportation, the resident can pay privately, and if the resident cannot pay, the facility will pay for it.On October 3, 2025, at 4:23 p.m.
during a telephone interview with Resident 1's FM, the FM stated the facility was sending Resident 1 to her dialysis appointments via Uber. The FM stated Resident 1 had an operation on her feet and was not supposed to put pressure on her feet and that she needed a lifted van for a wheelchair transfer. The FM stated he had a meeting with the facility on October 1, 2025, and they said they would take care of the transportation, but he did not hear from them.On October 3, 2025, a review of Resident 1's care plan revealed no interventions addressing transportation to dialysis, transfer assistance, or mobility safety.There was no revision to the care plan after the transportation method changed or after the injury occurred.There was no documentation of resident or family participation in developing or revising the care plan regarding transportation method to and from dialysis.Cross refer to F-F684
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
10/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Riverside Postacute Care
8781 Lakeview Avenue Riverside, CA 92509
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0684
F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
transportation that's reliable to come to the facility at 4:00 a.m. When asked if it was acceptable to transport
a resident by Uber without first determining the appropriate mode of transportation, the ADM stated that doing so poses a risk or injury to the resident compared to a wheelchair van transportation.A review of Resident 1's GACH records titled, Physician Chart dated October 4, 2025, indicated Resident 1 arrived at
the Emergency Department at 1:34 a.m., and on physical examination Resident 1 had bruising on the right and left side of her torso, between the lowest rib and the hip, with mild tenderness when touched.A review of Resident 1's Computed Tomography (CT) Scan (a diagnostic imaging test that created detailed pictures of the inside of the body) of the chest dated October 4, 2025, indicated Resident 1 had right breast and chest muscle hematoma (localized collection of blood) and soft tissue swelling, side right chest wall subcutaneous (under the skin) soft tissue swelling probable contusion (bruise), possible nondisplaced lateral right rib fractures (a type of bone fracture where the broken bone pieces remain in their original position).A review of the facility's policy titled, Transportation, Social Services dated January 2018, indicated .Our facility shall help arrange transportation for residents as needed .Social services will help the resident as needed to obtain transportation .
Event ID:
Facility ID:
If continuation sheet
RIVERSIDE POSTACUTE CARE 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 POSTACUTE CARE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.