Some nursing homes in California are categorized as Special Focus Facilities by the Centers for Medicare and Medicaid Services (CMS) because they failed to provide minimal standards of care to their residents. By law, these facilities must take appropriate measures to ensure that all problems are immediately corrected to help maintain the health and well-being of those under their care. To ensure much-needed policies and procedures are enforced, the federal agency routinely monitors the nursing home using surveyors and investigators. These surveys are conducted through scheduled appointments and unexpected investigations anytime throughout the year when inquiring about formally filed complaints.
Currently, Riverside Heights Health Care Center is designated as a Special Focus Facility because of serious safety problems that routinely occurred at the nursing home. The Healthcare Center was given the opportunity to take appropriate measures to develop, implement and enforce affected policies and procedures to ensure that every resident receives at least the basic standards of care without the potential of being harmed, injured or killed by preventable conditions, hazards, and dangers.
The facility will maintain this unwanted designation until all necessary corrections have been made and numerous follow-up surveys and investigations have been taken to ensure that the policies and procedures of providing quality care are permanent. A failure to do so over time could terminate the contract the facility has with Medicare and Medicaid.
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 Health Care Center is a special focus facility Medicare/Medicaid-participating 70-certified bed for-profit nursing facility providing care and services to the residents of the city of Riverside and Riverside County, California. The facility is located at:
8951 Granite Hill Dr.
Riverside, CA 92509
(951) 685-7474
The serious violations and ongoing failures occurring at Riverside Heights Health Care Center lead to serious penalties issued by state investigators. Over the last three years, the facility received fines of $92,598 (October 10, 2016) and $26,250 (January 26, 2017).
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.
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 Ensure That Every Resident Receives the Necessary Care and Services to Maintain Their Highest Well-Being
In a summary statement of deficiencies dated January 26, 2017, the state investigator noted the facility’s failure “to ensure specific cares and services were provided for [three residents at the facility].” In an incident involving one resident, “the facility was not able to obtain pacemaker information since [the resident was admitted]. This failure had the potential to delay the facility staff’s response to treatment of [the resident’s condition].”
In a separate incident with another resident, “the facility did not administer five medications as scheduled and did not notify the physician when there was a delay in the pharmacy delivery. This failure had the potential to alter the resident’s medication management related to pain, blood pressure, behavior and reflux (a condition when the stomach acid or, stomach content backs up] in the food pipe.” A third resident was affected when the facility “did not follow up on the weight committee’s recommendation for an iron supplement. This failure had the potential for the resident not to receive the recommended amount of iron in the blood and delayed nutritional management.”
Failure to Ensure That Every Resident Entering the Nursing Home without a Catheter Is Not Given Catheter and Receives Proper Services to Prevent Urinary Tract Infections
In a summary statement of deficiencies dated January 26, 2017, the investigator noted the facility’s failure “to identify the periods of bladder incontinence (ability to control urine) and provide appropriate treatment services to restore normal bladder function, as possible, for [one resident at the facility].” Investigators noted that “this failure resulted in missed opportunities to provide bladder retaining for [a resident] for … October through December 2016.”
The State surveyor noted that the facility failed to follow their Urinary Continence and Incontinence – Assessment and Management policy and procedure dated September 2010 that reads in part:
“The physician and staff should provide appropriate services and treatment to help residents restore or improve bladder function. Staff will define each individual’s level of incontinence. As part of its assessment, nursing staff will seek and document details related to continents. The nursing staff and physician will identify risk factors for becoming incontinent or for worsening of current incontinence. The staff will document the results of the toileting trial in the resident’s medical record. The staff and physician will evaluate the effectiveness of interventions.
Failure to Ensure That Every Resident Remained Protected from Serious Medical Mistakes
In a summary statement of deficiencies dated January 26, 2017, investigators noted the facility had failed to “ensure a physician’s orders” were followed. An observation of a medication pass was made on January 23, 2017, at 8:00 AM. Surveyors noted that the pharmacy label on drugs being administered to two residents “did not match the physician’s orders. The surveyor interviewed the facility’s Assistant Director of Nursing who stated that the “resident’s order was correctly transcribed from the hospital record on the MAR (Medication Administration Record).” However, “the medical record staff was not able to correctly reproduce the order on the electronic MAR and the initial and monthly physician’s recalculation orders.”
The State surveyor stated that the facility had failed to follow their policy titled Medication Ad. Here ministration – General Guidelines that reads in part:
“Prior to administration, the medication and doses schedule on the resident’s MAR shall be compared to the medication label. If the label and the MAR are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions… Medication shall be administered in accordance with written orders of the attending physician.”
Failure to Properly Store, Cook and Serve Food in a Safe and Clean Manner
In a summary statement of deficiencies dated January 26, 2017, an observation was made revealing that the facility had failed to “store food under sanitary conditions when [hazardous food] was observed inside the refrigerator, available for use. This failure increased potential to result in foodborne illnesses including nausea, vomiting, and diarrhea, and a medically vulnerable resident population.”
Failure to Develop a Program That Investigates, Controls and Keeps Infections from Spreading
In a summary statement of deficiencies dated January 26, 2017, the state investigator noted the facility’s failure “to implement a safe and appropriate handling of medical waste when the facility’s bile hazard container was unsecured and located in an area accessible to residents and unauthorized individuals. It was noted that this failure “had the potential for increased risk of cross-contamination and the spread of infection to the resident the s, staff, and visitors at the facility.”
Failure to Provide Necessary Cares and Services to Maintain the Highest Well-Being of the Resident
In a summary statement of deficiencies dated February 3, 2017, the state investigator noted that the facility had failed “to provide the necessary care and services to obtain the highest quality of care [for a resident]. The facility nurses were not properly providing treatment for [the resident’s condition that resulted in the resident] developing dry and wet gangrene (death of body tissue resulting from obstructive circulation or infection) of both feet.” The results of the neglect resulted in “required acute care hospitalization, which subsequently may require above-the-knee amputation for both extremities.”
A family member filed a formal complaint against the facility. As a result, State surveyor conducted an unannounced complaint visit on December 22, 2016. The resident’s family member stated that the “physician made a recommendation of amputating both of his legs at an acute care hospital due to no circulation.”
The family member at stated that “facility nurses did not assess his feet during his stay at the facility [… and] in the first week of December, she received a call from the facility that [their loved one] had an altered level of consciousness and needed to be transferred to the hospital.” The family member also stated that their loved one “had gangrene on both feet.” The State surveyor interviewed the facility’s Assistant Director of Nursing who stated that “there were no residents at the facility with foot wound issues.”
Failure to Provide Proper Care for Residents Requiring Special Services
In a summary statement of deficiencies dated February 3, 2017, the state investigator noted the facility’s failure “to provide treatment and care for [a resident’s circulatory condition in which narrow blood vessels reduced blood flow to the limbs of the lower legs.” This problem was revealed after a podiatrist’s assessment indicated there were “no pedal pulses felt on multiple elevations [and] there was no communication amongst nurses to monitor the decrease pulses of the feet and no Plan of Care for [the resident’s medical condition].”
The failure of the nursing staff resulted in “further complications of decreased circulation, gangrene (death of body tissue resulting from obstructive circulation or infection) of the feet, infection, and a recommendation from the vascular surgeon to amputate above the knees.”
Failure to Ensure That Every Resident Remained Free from Accidental Hazards
In a summary statement of deficiencies dated January 26, 2017, the state investigator noted the facility’s failure to ensure that a resident “received adequate supervision to prevent an accident. This failure resulted in [the resident] having a fall, and suffered a left shin and left ankle fracture that required three surgical treatments to repair a left ankle fracture.” It was also noted that there was a failure in ensuring that the resident “was assessed for safety and appropriate use of side rails. This failure had the potential to put the resident at risk for injuries from accidents and entrapment.”
Failure to Provide Appropriate Leadership to a Medically Vulnerable Population
In a summary statement of deficiencies dated November 11, 2016, the state investigator noted the facility’s failure “to provide appropriate leadership to the facility staff by providing services to the [residential] population.” This failure was evidenced by 1.) A staff member “was terminated and the Administrator was unaware of the incident”; and 2.) Another staff member “voluntarily left the facility for not being able to verbalize concerns with the quality of care for the residents at the facility to the State surveyors.”
The surveyors noted that these failures “have the potential to cause a negative and hostile work environment for the residents and subsequently cause the residents and facility staff to feel powerless and unprotected by management.” The findings of the incident revealed that on the morning of November 4, 2016, “a complete investigation was conducted at the facility regarding retaliation going on against employee staff who spoke out about management or conditions at the facility.”
The State surveyor interviewed the facility’s Director of Nursing that morning who stated that “there was one faculty staff member that was terminated last week [and that] she was not getting an appropriate response from her when asked about the weekly wound summary of a resident.” By November 7, “a follow-up complaint visit was conducted at the facility,” and an interview with the facility Administrator was conducted who stated that “she was unaware of why the Director of Nursing terminated the [employee].”
Failure to Ensure the Residents Remained Safe from Serious Medical Mistakes
In a summary statement of deficiencies dated November 11, 2016, the state investigator noted the facility’s failure “to ensure that residents were free from any significant medication errors when there was evidence that medications were not administered as ordered by the doctor on September 24, 2016. These failures placed the resident at risk for possible unforeseen medical complications.”
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.”
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. Contact us today! 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.
View our page on California nursing home laws and regulations here.
For material related to specific inspection reports and attorneys serving specific cities, look at the pages below:
Attorney Anthony Lanzone
Licensed in California
Riverside County Nursing Home Injury Attorney Nursing Home Law Center LLC Home