Other·September 14, 2017

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated standard survey for the investigation of one complaint. Complaint numbers CA00538868 linked with CA00544011. Representing the California Department of Public Health: Surveyor Federal ID number 33841, HFEN. The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for complaint number CA00538868 linked with CA00544011.

F204 SS=D PREPARATION FOR SAFE/ORDERLY TRANSFER/DISCHRG CFR(s): 483.15(c)(7)

F204 08/01/2017 (c)(7) Orientation for Transfer or Discharge A facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to ensure Resident A's responsible party was provided sufficient preparation, and orientation prior to transfer, LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D41W11 Facility ID: CA240000072 If continuation sheet 1 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555365 (X3) DATE SURVEY COMPLETED 08/01/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALM TERRACE CARE CENTER 11162 Palm Terrace Ln Riverside, CA 92505 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE when resident was transferred from one facility to another without the consent of the responsible party for one (Resident A) of three sampled residents. This failure had resulted in Resident A's responsible party not to be provided with the opportunity to be part of the discharge plan for Resident A. Findings: On June 12, 2017, at 9:25 a.m., an unannounced visit to the facility was conducted to investigate a complaint related to transfer/discharge issue. On June 12, 2017, Resident A's record was reviewed. Resident A was readmitted to the facility on April 24, 2017, with diagnoses which included muscle weakness and dementia (general term for a decline in mental ability severe enough to interfere with daily life). Resident A's physician's progress notes dated May 27, 2017, indicated, "Pt (patient) was seen today talked c (with) facility administrator I explained to (name of the Administrator) it could be detrimental to move pt from (name of the facility) which has been her (Resident A) home in last 4 years..." Resident A's physician and telephone orders dated June 8, 2017, indicated, "Clarification: Transfer resident to (name of Facility 2) for continuation of care in a locked facility secondary to dementia." Resident A's elopement/wandering risk assessment indicated the following: a. April 24, 2017, score of 21, (a score of 20 or higher is at risk), remains at risk - attempts to exit doors, plan: 1-1 by nsg (nursing) staff, or DON (Director of Nursing) office, nsg station; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D41W11 Facility ID: CA240000072 If continuation sheet 2 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555365 (X3) DATE SURVEY COMPLETED 08/01/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALM TERRACE CARE CENTER 11162 Palm Terrace Ln Riverside, CA 92505 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and b. June 2, 2017, score of 21, attempts to exit, usually redirected by staff risk for injury, or fall if unwitnessed, plan: 1-1 at nursing station, DON office pending discharge to lock facility. Documents provided by the administrator indicated the following: a. Meeting held May 26, 2017, safety issues and liability concerns for Resident A were discussed with the responsible party but continued to disagree with discharge plan. b. Meeting held May 27, 2017, meeting with the physician, Resident A's physician stated he would not voluntarily recommend the transference of the resident (Resident A) to an appropriate facility. The doctor requested for the facility (Facility 1) to keep the patient for 4.-6 weeks then go from there. c. Meeting held on June 2, 2017, several incidents were discussed with the physician related to Resident A. The conversation concluded with the physician stating to convince and inform the responsible party about the transfer, but was requested to provide written documentation stating he was against the recommendation for a safe transfer to a better facility for a patient. d. June 8, 2017, the physician was notified of the intent to transfer. Resident A's physician requested that the facility assist the daughter with placement, preferably in Orange County. e. June 8, 2017, approximately 5 p.m., the administrator called the responsible party and was advised regarding the intent to transfer. The document further indicated Resident A's family member becoming hostile and stated, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D41W11 Facility ID: CA240000072 If continuation sheet 3 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555365 (X3) DATE SURVEY COMPLETED 08/01/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALM TERRACE CARE CENTER 11162 Palm Terrace Ln Riverside, CA 92505 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE "The state says you can't do this." There was no evidence of documentation indicating Resident A's family member provided consent with the transfer to the locked facility (Facility 2). On June 13, 2017, at 11:01 a.m., the Administrator was interviewed. He stated he had several conversations with Resident A's family member prior to the resident being transferred to the locked facility (Facility 2). The Administrator was asked if during the conversation Resident A's family member consented on the transfer, he stated "NO". On June 14, 2017, at 12:53 p.m., Resident A's responsible party was interviewed. She stated the facility called her last May 26, and June 2, 2017, to discuss the plan of transferring Resident A. Resident A's responsible party stated she did not want the resident to leave since the resident had been at the facility for a long time (4 1/2 years). She stated she never consented to the transfer of Resident A to the other facility (Facility 2). Resident A's responsible party stated she did not receive a 30 day notice prior to transfer. On June 19, 2017, at 2:29 p.m. the Social Worker (SW) was interviewed. She stated she was not able to talk to Resident A's family member the day of the transfer to the other facility. The SW stated she told the receiving facility (Facility 2) Resident A's family member was notified. She did not know whether the family member consented to the transfer. The facility policy and procedure was reviewed. The policy titled, "Discharge, Transfer, Readmission Rights," revised November 28, 2016, indicated,"Policy 1. Appropriate arrangements for post facility care, including FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D41W11 Facility ID: CA240000072 If continuation sheet 4 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555365 (X3) DATE SURVEY COMPLETED 08/01/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALM TERRACE CARE CENTER 11162 Palm Terrace Ln Riverside, CA 92505 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE but not limited to, care at...another skilled/nursing facility...are made upon and prior to a resident's discharge from the facility to assure the most appropriate discharge for the resident. Guidelines. Facility will...Develop a discharge plan for each resident that is included in the Comprehensive Care Plan and evaluated/updated...Notify in writing the resident and if known, the resident representative of the transfer or discharge and reasons for the move...The notice will be made, at least thirty (30) days before the resident is transferred or discharge unless the transfer is made for medical, health, and safety reasons... Upon discharge to a non-acute care setting, the resident and the representative...will a. Review and receive a copy of the thrty (30) day discharge/transfer notice..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D41W11 Facility ID: CA240000072 If continuation sheet 5 of 5