Other·January 23, 2019

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 number: CA00606024 Representing the California Department of Public Health: Surveyor 37569/3134, HFEN The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. The complaint allegations were unsubstantiated, however, additional violations of the regulations were found, and deficiencies were issued for complaint number CA00606024.

F623 SS=D Notice Requirements Before Transfer/Discharge CFR(s): 483.15(c)(3)-(6)(8)

F623 11/20/2018 §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State LongTerm Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in 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: MINR11 Facility ID: CA240000072 If continuation sheet 1 of 22 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 10/31/2018 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 paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MINR11 Facility ID: CA240000072 If continuation sheet 2 of 22 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 10/31/2018 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 Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l). This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure Notice of Transfer/Discharge was sent to the State LTC FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MINR11 Facility ID: CA240000072 If continuation sheet 3 of 22 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 10/31/2018 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 Ombudsman's Office (state agency advocates for long-term or LTC care residents and families) for one of three sampled residents (Resident A) as required, at the time of discharge. This failure increased the potential risk for Resident A and her family members (FM 1 and FM 2) to be uninformed of discharge rights, and limited the ability of the Ombudsman to assist Resident A. Findings: On October 9, 2018, at 3:35 p.m., the Ombudsman for the facility was interviewed by telephone. The Ombudsman stated she had no information about Resident A and was not aware of any complaint. On October 10, 2018, at 8:45 a.m., an unannounced visit was made to the facility for the investigation of one complaint that concerned Resident A. On October 10, 2018, beginning at 9:16 a.m., Resident A's record was reviewed. The record indicated Resident A was admitted to the facility on August 27, 2018, from (name of hospital). The Record indicated Resident A had a history of deafness (inability to hear), cancer, seizures (sudden, involuntary movements of body or limbs usually caused by brain injury or disease), and weakness. The History and Physical, dated August 29, 2018, indicated Resident A had the capacity to make decisions. The Physician's Order, dated September 27, 2018, untimed, indicated, "...Discharge to (name of Board and Care facility) on 09/28/2018..." On October 10, 2018, at 10:25 a.m., the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MINR11 Facility ID: CA240000072 If continuation sheet 4 of 22 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 10/31/2018 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 Director of Nursing (DON) was interviewed. The DON stated she remembered Resident A. The DON stated Resident A was on reverse isolation (measures used to prevent resident from getting infections from other residents or staff used for residents with severely weakened immune system) at the facility, and hospice care was considered for Resident A. On October 10, 2018, at 10:30 a.m., the Director of Social Services (DSS) was interviewed. The DSS stated Resident A was discharged to a Board and Care facility on September 28, 2018 and Resident A's family was not present for the discharge. Resident A's record was further reviewed. The "Notice of Transfer/Discharge" form signed by the DSS and dated September 28, 2018, indicated, "...Person Notified: (name of FM 1)...Effective Date: 9-28-18..." The area on the form marked "Notification Date" was blank. The area of the form that indicated, "...If you believe that the proposed transfer/discharge is inappropriate...you have the right to appeal...If you need assistance...you may contact..." was blank. The area of the form for Resident A or her responsible party's signature indicated, "unable to sign." The area of the form used to indicate the State LTC Ombudsman was notified of Resident A's transfer to the Board and Care facility was blank. On October 16, 2018, at 9:14 a.m., the clerk (CL) at the State LTC Ombudsman office was interviewed by telephone. The CL stated the Ombudsman's office did not receive a copy of the " Notice of Transfer/Discharge" form and had no record of Resident A's discharge from the facility on September 28, 2018. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MINR11 Facility ID: CA240000072 If continuation sheet 5 of 22 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 10/31/2018 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 On October 16, 2018, at 10 a.m., the DON was interviewed by telephone. The DON stated the DSS initiated the discharge process usually three days before the resident was discharged from the facility. The DON stated she did not know why Resident A's discharge forms were not completed. On October 16, 2018, at 10:10 a.m., the DSS was interviewed by telephone. The DSS stated she notified Resident A's doctor that Resident A no longer needed skilled care at the facility. The DSS stated she then notified nursing staff to get the Physician's order to discharge Resident A to the Board and Care facility. The DSS stated she spoke to FM 2 on the telephone about Resident A's discharge. When asked why the "Notice of Transfer/Discharge" form indicated FM 1 was contacted, the DSS stated the form should have indicated FM 2 was contacted and, "...may have been an error on my part..."The DSS further stated the Ombudsman office should be notified by fax when the Notice is issued to the family. A facility provided copy of a fax to the Ombudsman was reviewed and did not contain any resident specific information to indicate Resident A's "Notice of Transfer/Discharge" was sent.

F624 SS=D Preparation for Safe/Orderly Transfer/Dschrg CFR(s): 483.15(c)(7)

F624 11/20/2018 §483.15(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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MINR11 Facility ID: CA240000072 If continuation sheet 6 of 22 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 10/31/2018 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 can understand. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide discharge instructions for one of three sampled residents (Resident A) to include medications, oral care, diet, and continued plan of care, when Resident A was discharged from the facility. This failure increased the potential risk for harm and a decline in Resident A's health status, and may have contributed to Resident A's transfer to the emergency room the day after she was discharged. Findings: On October 1, 2018, a complaint was received concerning Resident A. The complaint indicated Resident A's family members (FM 1 and FM 2) saw Resident A at (name of hospital) emergency room on September 29, 2018, and FM 1 and FM 2 were concerned about a lesion on Resident A's lip. On October 10, 2018, at 8:45 a.m., an unannounced visit was made to the facility for the investigation of one complaint. On October 10, 2018, beginning at 9:16 a.m., Resident A's record was reviewed. The record indicated Resident A was admitted to the facility on August 27, 2018, from (name of hospital). The record indicated Resident A had a history of deafness (inability to hear), seizures (sudden, involuntary movements of body or limbs usually related to brain injury or disease), cancer, and weakness. On October 10, 2018, at 10:30 a.m., the Director of Social Services (DSS) was interviewed. The DSS stated she remembered FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MINR11 Facility ID: CA240000072 If continuation sheet 7 of 22 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 10/31/2018 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 Resident A. The DSS stated Resident A's family was not present for Resident A's discharge; and, the DSS arranged for Resident A to be transported to (BC-name of Board and Care facility) on September 28, 2018. The DSS stated Resident A was examined by the facility's Dentist on the day she was discharged from the facility. On October 10, 2018, at 10:44 p.m., Certified Nursing Assistant (CNA) 1 was interviewed. CNA 1 stated she remembered Resident A. CNA 1 stated Resident A was totally dependent on the facility staff for her daily care. CNA 1 stated Resident A developed a blister and red painful areas on her lips that hurt Resident A when she tried to eat. CNA 1 stated the doctor ordered medication to be applied to Resident A's mouth and lips. On October 10, 2018, at 11:15 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated she remembered Resident A. LVN 1 stated Resident A could read lips and communicate by tapping the nurse's hands to say "no." LVN 1 stated Resident A required assistance to eat. LVN 1 stated she notified Resident A's doctor because Resident A refused to eat. LVN 1 stated Resident A's doctor ordered Nystatin (medication used to treat painful fungus infections of the mouth) for the red, painful areas on Resident A's lips. LVN 1 stated the first two doses were too painful for Resident A to take in her mouth, but Resident A's mouth started to improve with the medication. Resident A's record was then further reviewed. The History and Physical (H & P), dated August 29, 2018, indicated Resident A had the capacity to make decisions. The Physician's Order dated September 25, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MINR11 Facility ID: CA240000072 If continuation sheet 8 of 22 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 10/31/2018 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 2018, indicated Resident A's physician ordered, "...Nystatin...5 ML (ML milliliter-a unit of measure)...by mouth swish and swallow four times daily for 7 days for inflammed (sic) lower lip and tongue..." The Physician's Order, dated August 28, 2018, indicated Resident A's diet was, "...Puree with Nectar thick liquids (all foods pureed consistency and all liquids thickened)..." The Physician's Order, dated September 27, 2018, untimed, indicated Resident A was to be discharged from the facility September 28, 2018 with, "...same medications including Norco...Paxil...Trazadone (medications used to treat pain and depression)...Home Health to follow up...follow up with PCP (primary doctor) within 1 weeks (sic) of discharge and with Oncologist (Cancer specialist)..." The order did not indicate instructions for Resident A's diet, oral care, activity level, or when Resident A was supposed to see her Oncologist. The Dental Consult, dated September 28, 2018, untimed, indicated, "...Pt (patient) unable to tolerate brushing causing gums to bleed. Observed white, yellow lesion on tongue and left lower lip. Rec (recommend) pt be seen by specialist, oncologist." The Nurse's Notes, dated September 28, 2018, at 3:05 a.m., indicated, "...Cont (continue) on nystatin swish and swallow for oral thrush and inflamed lower lip and tongue...lower lip and tongue still inflamed. Oral care given..." The Nurse's Notes, dated September 28, 2018, at 1:19 p.m., indicated, "...Resident alert and awake...discharge today to board and care (name of facility) with same medications including Norco, Paxil, and trazadone...Resident unable to sign any papers SS (Social Services staff) aware. Discharged at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MINR11 Facility ID: CA240000072 If continuation sheet 9 of 22 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 10/31/2018 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 1300 (1 p.m.) via w/c (wheelchair) by (name of company) transportation." The "Notice of Transfer/Discharge" form, was reviewed. The form signed by the facility's DSS and dated September 28, 2018, indicated,"...Name of Person Notified: (name of FM 1). The area on the form marked "Notification Date" was blank. The area of the form that indicated,"...If you believe the proposed transfer/discharge is inappropriate...If you need assistance...contact...telephone..." was blank. The area for Resident A or her responsible party's signature indicated, "unable to sign." The Discharge Instructions form, dated September 28, 2018, was reviewed. The areas on the form that stated "...I understand the above discharge instructions...I have received the medication instructions..." where Resident A or her responsible party were supposed to sign to indicate they received instructions on Resident A's plan of care and medications were blank. The instructions written on the form indicated Resident A was supposed to see her primary doctor in one week. The area on the form for Resident A to sign indicated,"...Patient/Representative Signature: unable to sign..." The area of the form to provide Resident A's pharmacy name and telephone number indicated,"...NA no information given by pt..." The areas on the form to indicate Resident A's primary care doctor name, telephone number, Physician Specialist, pharmacy, and pharmacy telephone number were all blank. There was no documented indication of the Dentist's recommendations for Resident A. The second Discharge Instruction form, dated September 28, 2018, was reviewed and indicated, "Discharge Location...(name of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MINR11 Facility ID: CA240000072 If continuation sheet 10 of 22 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 10/31/2018 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 Board and Care facility)..." with an address listed. The form further indicated, "...Activity As tolerated...Diet...Soft..." The Physician's Order, noted above, did not contain orders for diet and activity. The document titled "Active Orders Report," dated September 28, 2018 (used to list all of Resident A's prescribed medications at the time of discharge) was reviewed. The document indicated Resident A was prescribed 18 scheduled medications and seven "as needed" medications, including the Nystatin and anti-seizure medications. The first scheduled medication on the list indicated, "...Order Date 09/25/2018...Stop Date 10/02/2018... Nystatin...by mouth four times daily for 7 days for inflammed (sic) lower lip and tongue..." The Physician's Discharge Summary form indicated,"...Discharged to: Home..." and listed a home address different than the Board and Care address noted above. The areas on the form for final discharge diagnosis, prognosis, physician signature, and date were blank. There was no documented evidence of Resident A's course of treatment at the facility, plan of care, test results, consultations including the Dental consult, medication reconciliation, prescribed diet, or post discharge plan of care. On October 16, 2018, at 9:14 a.m., the clerk at State LTC Ombudsman office (CL) was interviewed by telephone. The CL stated they did not receive notice of Resident A's discharge from the facility as required. On October 16, 2018, at 10 a.m., the Director of Nursing (DON) was interviewed by telephone. The DON stated the DSS initiated the discharge process three days before a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MINR11 Facility ID: CA240000072 If continuation sheet 11 of 22 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 10/31/2018 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 resident was discharged. The DON stated the Physician was notified and may or may not come see the resident before they were discharged. The DON stated the RN Supervisor gave discharge instructions to the resident at the time of discharge. The DON stated the RN should document who the instructions were given to and if the instructions were understood. The DON stated all ordered medications left at the facility were supposed to be sent with the resident at the time of discharge. The DON stated the resident's pharmacy information was obtained so new medications were available when the resident arrived at the new facility. The DON stated she did not know why Resident A's discharge instructions and forms were not completed. On October 16, 2018, at 10:10 a.m., the DSS was interviewed by telephone. The DSS stated she notified Resident A's doctor that Resident A no longer needed skilled care at the facility. The DSS stated she then notified nursing staff to get the Physician's order to discharge Resident A. The DSS stated she spoke to FM 2 about Resident A's proposed discharge. When asked why the, "Notice of Transfer/Discharge" form indicated FM 1 was contacted and the notification date was blank, the DSS stated, "...may have been an error on my part..." On October 16, 2018, at 12:40 p.m., the Registered Nurse Supervisor (RN) 1 was interviewed by telephone. RN 1 stated she remembered that Resident A was deaf. RN 1 stated on September 28, 2018, Resident A was alert, calm, and non-verbal. RN 1 stated she attempted to give discharge instructions to Resident A but didn't finish because RN 1 did not know if Resident A understood when RN 1 was talking to her. RN 1 stated she asked the DON who else to give the discharge instructions to. RN 1 stated the DSS told her FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MINR11 Facility ID: CA240000072 If continuation sheet 12 of 22 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 10/31/2018 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 discharge instructions were "already given." RN 1 stated she did not remember if the Nystatin or other medications were sent with Resident A at discharge. On October 16, 2018, at 1:05 p.m., the DSS was further interviewed by telephone. The DSS stated Resident A's Physician did not come to the facility to examine Resident A before she was discharged. The DSS stated there were no Physician's notes in Resident A's record after the H & P on August 29, 2018. The DSS stated she gave a copy of the discharge forms and list of medications to (first name of Board and Care staff) who came to the facility on August 27, 2018. The DSS stated she gave (name) Resident A's discharge date and instructions about home health, and "...I gave verbal instructions...didn't have her sign the form..." The DSS stated RN 1 or "the nurse" gave Resident A's discharge instructions and discussed medications with (name) on September 27, 2018. On October 16, 2018, at 1:20 p.m., RN 1 was further interviewed by telephone. RN 1 stated she was not notified of Resident A's discharge orders until September 28, 2018, and did not meet with or discuss Resident A's discharge or medications with (name) from the Board and Care facility. There was no documented evidence that Resident A's discharge instructions, including discharge plan of care, medications including Nystatin, diet, and oral care needs or a completed discharge summary were provided before Resident A was discharged from the facility on September 28, 2018. The facility policy and procedure, titled, "Transfer/Discharge of A Patient," undated, was reviewed and indicated, "...Notify attending FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MINR11 Facility ID: CA240000072 If continuation sheet 13 of 22 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 10/31/2018 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 physician, family, or responsible party...Be sure relative or responsible party has completed all necessary arrangements with...Charge Nurse, and has signed for any medication to be taken with patient. Have family...sign, if patient is unable to sign the discharge...Complete chart...include name and amount of medication released...If transferring ...to other institution...Fill out transfer form indicating medication and/or treatments given within last 24 hours...Insure ...a copy of ...records are forwarded with the transfer of the patient...send patient's medications with transcript of physician's orders..."

F661 SS=D Discharge Summary CFR(s): 483.21(c)(2)(i)-(iv)

F661 11/20/2018 §483.21(c)(2) Discharge Summary When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following: (i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. (ii) A final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MINR11 Facility ID: CA240000072 If continuation sheet 14 of 22 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 10/31/2018 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 (iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-thecounter). (iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any postdischarge medical and non-medical services. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure a discharge summary was completed for one of three sampled residents (Resident A) when Resident A was discharged to a Board and Care facility. This failure increased the potential for harm to Resident A, caused Resident A, her family members, and the Board and Care staff to be uninformed about Resident A's plan of care, and may have contributed to Resident A's transfer to the emergency room the day after she was discharged. Findings: On October 1, 2018, a complaint was received concerning Resident A. The complaint indicated Resident A's family members (FM 1 and FM 2) saw Resident A at (name of hospital) on September 29, 2018, and were concerned about a lesion on Resident A's lip. On October 1, 2018, at 8:45 a.m., an unannounced visit was made to the facility for the investigation of one complaint. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MINR11 Facility ID: CA240000072 If continuation sheet 15 of 22 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 10/31/2018 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 On October 10, 2018, beginning at 9:16 a.m., Resident A's record was reviewed. The record indicated Resident A was admitted to the facility on August 27, 2018, from (name of hospital). The record indicated Resident A had a history of deafness (inability to hear), brain cancer, seizures (sudden involuntary movements of body or limbs usually caused by brain injury or disease) , and weakness. On October 10, 2018, at 10:25 a.m., the Director of Nursing (DON) was interviewed. The DON stated she remembered Resident A. The DON stated Resident A was on reverse isolation (protective measures used to protect the resident from getting infections from other residents or staff used when residents have severely weakened immune system) while at the facility. The DON further stated Resident A was very ill and hospice care was considered for her at the facility. On October 10, 2018, at 10:30 a.m., the Director of Social Services (DSS) was interviewed. The DSS stated she remembered Resident A. The DSS stated she arranged for Resident A to be transported to (name of Board and Care facility) on September 28, 2018. The DSS stated Resident A saw the facility's Dentist on the day she was discharged. On October 10, 2018, at 10:44 a.m., Certified Nursing assistant (CNA) 1 was interviewed. CNA 1 stated Resident A was totally dependent on the facility's staff for her daily care. CNA 1 stated Resident A developed a blister and red painful areas on her lips that hurt when Resident A tried to eat. On October 10, 2018, at 11:15 a.m., License Vocational nurse (LVN) 1 was interviewed. LVN 1 stated she remembered Resident A. LVN 1 stated Resident A required assistance to eat. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MINR11 Facility ID: CA240000072 If continuation sheet 16 of 22 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 10/31/2018 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 LVN 1 stated she notified Resident A's doctor when Resident A refused to eat. LVN 1 stated Resident A's doctor ordered Nystatin (medication used to treat fungal infections of the mouth) for the red, painful areas on Resident A's lips. LVN 1 stated the first two doses were too painful for Resident A to take in her mouth, but Resident A's mouth started to improve with the medication. Resident A's record was further reviewed. The History and Physical (H & P), dated August 27, 2018, indicated Resident A had the capacity to make decisions. The Physician's Order, dated August 28, 2018, untimed, indicated Resident A's diet was, "...Pureed with Nectar thick liquids (foods pureed consistency, all liquids thickened). The Physician's Order, dated September 25, 2018, untimed, indicated, "...Nystatin...5 ML (Ml milliliter a unit of measure)...by mouth swish and swallow four times daily for 7 days for inflammed (sic) lower lip and tongue..." The Physician's Order, dated September 27, 2018, untimed, indicated Resident A was to be discharged from the facility September 28, 2018, with,"...same medications...Home Health...follow up with PCP (primary doctor) within 1 weeks (sic) of discharge and with Oncologist (Cancer specialist)..." The order did not indicate instructions for Resident A's diet, oral care, activity level, or when Resident A was supposed to see the Oncologist. The "Notice of Transfer/Discharge" form signed and dated by the DSS on September 28, 2018, was reviewed. The form indicated, "...Name of Person Notified: (name of FM 1)." The area on the form marked "Notification Date" was blank. The area of the form that indicated,"...If you FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MINR11 Facility ID: CA240000072 If continuation sheet 17 of 22 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 10/31/2018 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 believe the proposed transfer/discharge is inappropriate...If you need assistance...contact...telephone..." was blank. The area for Resident A or her responsible party to sign the form indicated, "unable to sign." The Nurse's Notes, dated September 28, 2018, at 3:05 a.m., indicated, "...Cont (continue) on nystatin swish and swallow for oral thrush and inflamed lower lip and tongue...lower lip and tongue still inflamed. Oral care given..." The Dental Consult, dated September 28, 2018, untimed, indicated, "...Pt (patient) unable to tolerate brushing causing gums to bleed. Observed white, yellow lesion on tongue and left lower lip. Rec (recommend) pt be seen by specialist, Oncologist." The Nurse's Notes, dated September 28, 2018, at 1:19 p.m., indicated, "...discharge today to board and care (name of facility) with same medications including Norco, Paxil, and trazadone (medications used to treat pain and depression)...Resident unable to sign any papers SS (social services staff) aware. Discharged at 1300 (1 p.m.) via w/c (wheelchair) by (name of company) transportation." The Discharge Instructions form, dated September 28, 2018, was reviewed. The areas of the form that stated,"...I understand the above discharge instructions...I have received the medication instructions..." where Resident A or her responsible parties were supposed to sign indicating they received instructions on Resident A's plan of care and medications was blank. The area of the form for, "Patient/Representative Signature" indicated, "unable to sign." The area of the form for Resident A's pharmacy name and telephone FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MINR11 Facility ID: CA240000072 If continuation sheet 18 of 22 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 10/31/2018 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 number indicated, "...NA no information given by pt." The second Discharge Instructions form, dated September 28, 2018, was reviewed and indicated, "...Discharge Location... (name of Board and Care Facility)...with an address listed. The form further indicated, "...Activity As tolerated...Diet...Soft..." The Physician's discharge order noted above did not include orders to specify Resident A's activity and diet. The document titled, "Active Orders Report," dated September 28, 2018 (used to list Resident A's prescribed medications at the time of discharge) was reviewed and indicated Resident A was prescribed 18 scheduled medications and seven "as needed" medications at the time of discharge. The Physician's Discharge Summary, unsigned or dated by the Physician, indicated, "Discharged to: Home..." and listed an address different from the Board and Care facility noted above. There was no documented evidence of Resident A's course of treatment at the facility, test results, consultations including the Dental consult, medication reconciliation including the Nystatin and multiple anti-seizure medications, prescribed diet, oral care instructions, discharge diagnosis, prognosis, or post discharge plan of care. On October 16, 2018, at 10 a.m., the Director of Nursing (DON) was interviewed by telephone. The DON stated the DSS initiated the discharge process three days before the resident was discharged. The DON stated the Physician was notified and may or may not come to the facility to see the resident before the resident was discharged. The DON stated she did not know why Resident A's discharge instructions and forms were not completed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MINR11 Facility ID: CA240000072 If continuation sheet 19 of 22 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 10/31/2018 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 On October 16, 2018, at 10:10 a.m., the DSS was interviewed by telephone. The DSS stated she notified Resident A's doctor that Resident no longer needed skilled care at the facility. The DSS stated she spoke to FM 2 about Resident A's proposed discharge. When asked why the Discharge Notification form indicated FM 1 was contacted and the notification date was blank, the DSS stated, "...may have been an error on my part..." On October 16, 2018, at 12:40 p.m., Registered Nurse (RN) 1 was interviewed by telephone. RN 1 stated she remembered that Resident A was deaf. RN 1 stated on September 28, 2018, she attempted to give discharge instructions to Resident A, but did not finish because she did not know if Resident A understood RN 1 when she was talking. RN 1 stated she asked the DON who else she could give the discharge instructions to. RN 1 stated the DSS told her the discharge instructions were "already given." On October 16, 2018, at 1:05 p.m., the DSS was further interviewed by telephone. The DSS stated Resident A's Physician did not come to the facility to examine Resident A before Resident A was discharged from the facility. The DSS stated there were no Physician's notes in Resident A's record after the H & P completed on August 27, 2018. The DSS stated she gave a copy of the discharge forms and a list of medications to (first name of a Board and Care staff member) who came to the facility on August 27, 2018. The DSS stated she gave (name) Resident A's discharge date and instructions about home health and "...I gave verbal instructions...didn't have her sign the form..." The DSS stated RN 1 or "the nurse" gave Resident A's discharge and medication instructions to (name) on August 27, 2018. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MINR11 Facility ID: CA240000072 If continuation sheet 20 of 22 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 10/31/2018 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 On October 16, 2018, at 1:20 p.m., RN 1 was further interviewed by telephone. RN 1 stated she was not aware of Resident A's discharge orders until September 28, 2018. RN 1 stated she did not give discharge instructions or discuss Resident A's medications with the Board and Care staff. There was no documented evidence a Physician's Discharge Summary was completed for Resident A to include Resident A's post discharge plan of care, medications, diet order, activity, and oral care needs. There was no documented evidence a Physician's Discharge Summary was provided to Resident A, FM 1 or FM 2, or the Board and Care facility at the time of Resident A's discharge. The facility policy and procedure, titled, "Transfer/Discharge of a Patient," undated, was reviewed. The policy indicated, "...Notify attending physician, family, or responsible party...Be sure relative or responsible party has completed all necessary arrangements...has signed for any medication to be taken with patient. Have family...sign, if patient is unable to sign the discharge section...If transferring to...other institution...Fill out transfer form indicating medication and/or treatments given in the last 24 hours. Insure...a copy of records are forwarded with...patient...send patient's medications with transcript of physician's orders..." The policy did not reflect all requirements of the regulation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MINR11 Facility ID: CA240000072 If continuation sheet 21 of 22 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 10/31/2018 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) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: MINR11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA240000072 (X5) COMPLETE DATE If continuation sheet 22 of 22