Riverside Heights Healthcare Center

Injured Riverside Heights Healthcare Center Residents Seeking Compensation

Both the State of California and the Centers for Medicare and Medicaid Services (CMS) conduct routine surveys and unannounced inspections to identify serious violations, health concerns, and deficiencies. When problems are found, the nursing home must make significant improvements to rectify the issues and undergo a follow-up inspection.

Some nursing homes have serious underlying problems that lead to severe harm or death of a resident. When this occurs, state and federal nursing home regulators can place the facility on the national Medicare watch list and designate the Home as a Special Focus Facility (SFF). The center will remain on the watch list and maintain its designation while undergoing many additional inspections, surveys, and investigations into filed formal complaints.

In 2017, Riverside Heights Healthcare Center was placed on the federal watch list and designated a Special Focus Facility. Since then, publicly available information has revealed that the nursing center has shown some improvement. Some of the egregious violations, safety concerns, and deficiencies are listed below.

Riverside Heights Healthcare Center

This Nursing Center is a “for-profit” Facility providing services and cares to the residents of Riverside and Riverside County, California. The 143-certified bed Home is located at:

8951 Granite Hill Dr.
Riverside, CA 92509
(951) 685-7474

Over $50,000 in Monetary Penalties

State and federal nursing home regulators have the authority to issue monetary penalties to any nursing facility in the State of California identified with egregious violations. These fines are meant to put the facility on notice that their substandard of care will no longer be tolerated.

Within the last three years, Riverside Heights Healthcare Center was issued two monetary penalties including a fine of $3020 on July 17, 2015, and another fine of $50,335 on January 13, 2017. Also, in January 2017, Medicare refused a request for payment from the facility due to substandard care. There were 28 filed formal complaints in the last three years that resulted in a citation and 15 facility-reported issues that also resulted in citations.

Current Nursing Home Resident Safety Concerns

Publicly available information on the care and services provided by every nursing facility in America can be found on the national Medicare.gov website. This data includes open investigations, incident inquiries, dangerous hazards, health violations, filed complaints, and safety concerns. Additionally, the website provides a comparative analysis tool through a star rating summary system where families can determine the best and worst nursing homes in their community.

Currently, Riverside Heights Healthcare Center maintains a below average two out of five stars rating compared all other facilities nationwide. This ranking includes one out of five stars for health inspections, four out of five stars for staffing, and two out of five stars for quality measures. Some safety hazards, violations, and deficiencies concerning this facility are listed below.

  • Failure to Provide an Environment Free of Verbal Abuse by the Nursing Staff

In a summary statement of deficiencies dated September 27, 2017, the state investigator noted the facility’s failure “to ensure [a resident] was treated with dignity when a Licensed Vocational Nurse (LVN) spoke to [the resident] harshly. The notation indicated that the LVN told the “resident to get off the phone, and by pushing [the resident’s] chest in order to get the resident back in the bed.” It was also noted that the facility had failed “to increase the potential for [a resident] and other residents being cared for by [the Licensed Vocational Nurse] to experience a loss of dignity and respect, and increase the probability for a loss of self-esteem.”

The state surveyors conducted an unannounced visit to the facility on the morning of June 20, 2017, to “investigate an entity-reported incident of the staff-to-resident altercation.” During an interview with the facility Administrator, the surveyor noted that the resident “was transferred to [an acute care hospital] on June 11, 2017, for further evaluation of an episode of high blood pressure.”

On June 20, 2017, the surveyor interviewed a resident who resides in a room close to the abused resident. This resident stated that the Licensed Vocational Nurse “is not very friendly, and doesn’t have a smile on his face. The resident further stated he overheard [the abused resident] yelling in the early morning of June 7, 2017, at the Licensed Vocational Nurse.”

The investigator interviewed the abused resident’s roommate that same morning who stated that “he heard the Licensed Vocational Nurse stating to [the abused resident] ‘you don’t need to be on the phone.’ [The roommate] stated he witnessed the Licensed Vocational Nurse push [the abused resident] on the chest, forcing the resident back into bed [and observed the nurse] continue to push [the abused resident] until the resident almost fell into the footboard of the bed.”

A second Licensed Vocational Nurse was interviewed that same day at 12:44 PM who stated that the [abused resident] reported that [the abusive LVN] poked him in the chest and pushed him into bed.” The second License Vocational Nurse stated that the resident told staff that the abusive LVN took the resident’s “cell phone away from him.”

The investigator reviewed the facility’s Interdisciplinary Team Note dated June 9, 2017. The document revealed that the resident “told the team that the Charge Nurse allegedly pushed [the resident] to bed and yelled ‘you need to relax and get off that phone’ before taking their cell phone away from the resident’s hands and placing it on the table before walking out.” The resident stated that the Charge Nurse “was poking him and was in his face, that’s when he said to the Charge Nurse not to touch him, and the Charge Nurse walked out.”

The facility was reminded of their Residents’ Rights – Skilled Nursing Facility policy that reads in part “to be treated with consideration, respective full recognition of dignity and individuality.”

  • Failure to Provide an Environment Free of Harm from Resident to Resident Altercations

In a summary statement of deficiencies dated September 26, 2017, the state investigator noted that the facility had failed to “update the smoking assessments for two residents to reflect the residents currently smoked. As a result, the two residents were permitted to smoke unsupervised” which lead to a failure to “increased potential for [both residents experiencing] harm or physical injuries while smoking unsupervised.” Also, “the lack of supervision led to an altercation between [both residents] and transfer and admission of [one of the residents] to an acute care psychiatric hospital.

As a part of the investigation, surveyors reviewed the facility’s July 11, 2017, Nursing Notes which revealed that a “resident [was] involved in an altercation with another resident while out on the back Smoking Patio.” The note also reveals that “while the other resident involved attempted to extinguish her cigarette, this resident attempted to take it from her and pulled/elbow to her in the shoulder.”

An interview with the Administrator on the morning of July 14, 2017, revealed that “the facility notified the police and, when the police arrived in the facility [the abusive resident] was acting up [whose] breath smelled like alcohol.” The abusive resident “was transferred [involuntarily for psychiatric evaluation and has] not returned to the facility since the transfer.”

  • In a separate summary statement of deficiencies dated August 30, 2017, the state investigator noted the facility’s failure “to develop a comprehensive Plan of Care after an allegation of being called inappropriate names.” This failure increased “the potential for [the resident] to not receive needed interventions to help the resident feel safe after the alleged verbal abuse.” The state investigator reviewed the resident’s records on August 10, 2017, along with an August 1, 2017, Nursing Note that revealed that the resident “was claiming that someone wearing a red shirt, who walked by her as she was sitting in the wheelchair outsider bedroom, called her an inappropriate word.”

A review of the resident’s Plan of Care was shared with the Director of Nursing on August 10, 2017, who acknowledged “a Plan of Care for the alleged verbal abuse was not completed.” The Director also stated that “the licensed nurses should have completed a Plan of Care after the alleged verbal abuse.” The facility was reminded of their Case Management Policy that reveals that “the Plan of Care is continually updated to reflect current resident needs at all times.”

  • In a third summary statement of deficiencies dated July 17, 2017, the investigator noted the facility’s failure “to implement a Care Plan with appropriate and measurable goals for [a resident] after she was hit by another resident.” Surveyors documented that this failure “increased the potential for [the abused resident] to experience increased episodes of feeling unsafe or not secured, or experience decrease social interaction.”

The state surveyor conducted an unannounced visit at 9:40 AM on April 4, 2017 “to investigate an entity-reported incident of a resident-to-resident altercation. During a concurrent interview with the Administrator, [the Administrator stated that the abusive resident] usually walked around the facility, but [could not be interviewed] due to dementia (loss of memory).”

The Administrator stated that the incident occurred on March 23, 2017, when the assaulted resident “was observed sitting in her wheelchair in the hallway and [the abusive resident] approach or began swinging at [her].” The assaulted resident “put up their left arm and was hit by [the abusive resident].”

The state investigator interviewed the Social Services Director at the facility who claimed that a Certified Nursing Assistant (CNA) witnessed the abusive resident “tapping [the assaulting resident’s] left arm in the hallway.” The Certified Nursing Assistant “separated the two residents, keeping both residents safe, and placed both residents on 72-hour monitoring.”

The investigator reviewed the assaulted resident’s March 23, 2017 Care Plan that revealed the “alleged aggressive behavior by another resident” with a goal that stated, “The resident will maintain the ability to seek social contact and stimulation through the review date.” It also said that the “resident will remain safe and secure in the facility and not suffer emotional distress.”

However, the investigator noted that “the goals did not indicate how the facility would measure the resident’s ability to seek social contact and stimulation or identify what the resident’s baseline ability for social contact and stimulation were… For the facility to be able to determine if that ability was maintained.” The investigator also stated that the “goals did not indicate how the facility would identify if the resident felt or remained safe and secure and without emotional distress [while] in the facility.”

The facility, nursing staff and administration were reminded of their undated Interdisciplinary Plan of Care Conference policy that reads in part “an interdisciplinary care planning conference identifies the resident’s needs and establishes obtainable goals.” The investigator noted that the facility “failed to ensure Care Plan goals for [the assaulted resident] were measurable.”

  • Failure to Provide Proper Treatment to Residents Who Requires Specialized Care

In a summary statement of deficiencies dated August 3, 2017, the state investigator noted the facility had failed to “ensure one [resident] had his gastronomy tube disconnected and flushed after his enteral feeding [where liquid nutrients are fed through a tube] was completed. This facility failure increased the potential for [the resident] to experience complications… including blockage of [the enteral feeding tube] and possible surgical intervention to replace a malfunctioning [tube].

An observation of the resident was made during the tour the facility on the morning of August 31, 2017. The resident “was observed to have his [medical device for feeding] connected to his enteral feeding, which was completed and turned off.” The investigator interviewed the facility’s Minimum Data Set Nurse who stated that “all tube feeding should be disconnected and [the medical device] flushed when the feeding was complete.” The nurse also stated that the resident’s medical device “should have been disconnected from the feeding pump when it was completed and [the device] should have been flushed with water.”

The facility’s Licensed Vocational Nurse was interviewed that same morning at 10:00 AM who stated that “any time a resident’s medical device feeding was complete, the resident’s [device] should be disconnected and [the device] should be flushed with water.” The facility was reminded of their March 2015 Maintaining Patency of Feeding Tube (flushing) policy that reads in part “the purpose of this procedure is to maintain patency [unobstruction] of a feeding tube. Flushed enteral feeding tubes with the prescribed amount of water during continuous feeding and before and after intermittent feedings.”

Want to File an Abuse or Neglect Case Against a California Nursing Home?

Were you, or loved one, seriously injured through abuse, neglect or mistreatment while a resident at Riverside Heights Healthcare Center or any California nursing home? If so, filing a claim for compensation can help ensure your family receives the monetary recover they deserve for your damages. With legal representation, an attorney can file all the required documents in the appropriate courthouse and handle your case to its successful resolution.

Typically, personal injury cases, wrongful death lawsuits, and nursing home neglect compensation claims are handled through contingency fee agreements. This arrangement means you have immediate access to your attorney will handle your case to its conclusion. Legal fees are paid only after the case has been resolved successfully through a negotiated out-of-court settlement or a jury trial award.

Learn more about California nursing home laws and regulations here.


Justia Lawyer Rating for Jonathan Rosenfeld

Client Reviews

Jonathan did a great job helping my family navigate through a lengthy lawsuit involving my grandmother's death in a nursing home. Through every step of the case, Jonathan kept my family informed of the progression of the case. Although our case eventually settled at a mediation, I really was impressed at how well prepared Jonathan was to take the case to trial. Lisa
After I read Jonathan’s Nursing Home Blog, I decided to hire him to look into my wife’s treatment at a local nursing home. Jonathan did a great job explaining the process and the laws that apply to nursing homes. I immediately felt at ease and was glad to have him on my side. Though the lawsuit process was at times frustrating, Jonathan reassured me, particularly at my deposition. I really felt like Jonathan cared about my wife’s best interests, and I think that came across to the lawyers for the nursing home. Eric