Riverside Postacute Care
RIVERSIDE POSTACUTE CARE in RIVERSIDE, CA — inspection on May 27, 2026.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
12:50 p.m., a CNA found him on the floor in his room. LVN 1 stated she was the charge nurse that
room closer to the nurses' station and the RN (RN 2) got an order from the MD for a 1:1 sitter which
he was found on the floor mat and had a skin tear on his left elbow which treatment was provided.
The MD and family were notified.On May 27, 2026, at 11:55 a.m., during a concurrent interview with the Staffing Coordinator (SC) and record review of the facility's assignment sheet for May 13, 2026, the SC stated a CNA was initially assigned to be the 1:1 sitter for Resident 2 for the night shift of May 13, 2026, but was cancelled due to overstaffing.
The SC stated the facility's plan was for the CNAs to alternate every 30 minutes in providing the 1:1 sitter.On May 27, 2026, at 12:09 p.m., during a telephone interview with RN 2, she stated she obtained the order of a 1:1 sitter for Resident 2 from the MD on May 13, 2026, after he fell, and she followed up with the SC to have extra staffing. RN 2 stated Resident 2 needed a 1:1 sitter for safety because even if he is in the wheelchair or in a low bed, he was still able to get himself on the floor. RN 2 stated during the morning shift (7am-3pm) on May 14, 2026, the DON asked her to notify Resident 2's MD that a 1:1 sitter was not necessary and the order was discontinued.On May 27, 2026, at 2:53 p.m., during an interview, the DON stated Resident 2 needed a 1:1 sitter due to his fall risk.
The DON stated they removed the 1:1 sitter for Resident 2 on May 14, 2026, and had CNAs alternate every 30 minutes instead.
The DON stated Resident 2 should have had a sitter on the night shift of May 13, 2026, as ordered.A review of the facility's policy and procedure titled Fall Prevention Program dated December 2016, indicated .the staff, with the input of the attending physician, will identify appropriate interventions to reduce the risk of falls.A review of the facility's policy and procedure titled Safety and Supervision of Residents dated January 2018 indicated .Our individualized, resident-centered approach to safety addresses safety and accident hazards for individuals residents .The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices .Implementing intervention to reduce accident risks and hazards shall include the following .communicating specific interventions to all relevant staff; assigning responsibility for carrying out interventions .ensuring the interventions are implemented .Monitoring the effectiveness of interventions shall include the following .ensuring that interventions are implemented correctly and consistently .
555330 05/27/2026
Riverside Postacute Care 8781 Lakeview Avenue Riverside, CA 92509
in accordance with accepted professional standards.
observation, interview, and record review, the facility failed to ensure the medical record accurately
assistance and meal intake tasks had multiple missing entries.This failure resulted in incomplete medical records and had the potential to result in ineffective communication between staff members in monitoring Resident 1's nutritional status and response to care.Findings:A review Resident 1's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses which included stroke (loss of blood flow to a part of the brain) with right-sided weakness and dysphagia (difficulty swallowing).A review of Resident 1's History and Physical dated April 30, 2026, indicated the resident has the capacity to understand and make decisions.A review of Resident 1's Care Plan Report dated May 1, 2026, indicated, .The resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) .cerebral infarction (stroke) with hemiplegia (weakness) right side (sic) .interventions included .EATING: The resident is totally dependent on 1 (one) staff for eating .A review of Resident 1's Documentation Survey Report for the month of May 2026, indicated the assistance for eating and nutrition-amount eaten tasks had missing entries on May 5, 6, 7, 11, 19, 2026, for breakfast and lunch; on May 8 and 9, 2026 for lunch; and on March 21, 2026 for dinner.On May 26, 2026, at 12:22 p.m., during a concurrent observation and interview, Resident 1 was in her room, lying in bed, turned to her left side, alert and awake. Resident 1 stated she was admitted to the facility due to a stroke that left her with right-sided weakness. Resident 1 stated she needs assistance to eat.On May 26, 2026, at 1:16 p.m., during a concurrent interview with Certified Nurse Assistant (CNA 1) and a record review of Resident 1's medical record, CNA 1 stated she assisted Resident 1 all the time with eating. CNA 1 stated Resident 1 ate 60 % of her meals and she documented it in the electronic charting. CNA 1 confirmed she was assigned to Resident 1 on May 7, 2026, for the 7-3 (morning) shift.
When asked to explain why there were no entries for breakfast and lunch on May 7, 2026, CNA 1 stated it was because the computer was not working and the facility did not have any Wi-Fi ( a wireless networking technology that enables electronic devices to connect seamlessly to a network) for three days.On May 26, 2026, at 3:08 p.m., during an interview with the Director of Staff Development (DSD) and record review of Resident 1's medical record, the DSD stated CNAs document on the POC (Point of Care - an electronic charting tool) ADL Task how the resident was assisted with eating and how much they consumed for meals, and these should be documented daily for breakfast, lunch, and dinner.
The DSD stated the ADL Tasks for assistance in eating and nutrition-amount eaten had incomplete documentation for the month of May 2026.
The DSD stated there is no evidence that Resident 1 ate meals on multiple dates.
The DSD stated the CNAs should document daily and accurately complete their charting.On May 27, 2026, at 2:53 p.m., during an interview with the Director of Nursing (DON), the DON stated anything that is not documented is not done.
The DON stated for Resident 1, how would they know if the resident was eating when there is no documentation.A review of the facility's policy and procedure titled, Charting and Documentation dated January 2018 indicated .All services provided to the resident .shall be documented in the resident's medical record.
The medical record should facilitate communication between the interdisciplinary [NAME] regarding the resident's condition and response to care .
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.