Health inspection·May 1, 2023

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the provision of necessary respiratory care and treatments were consistent with professional standards of practice, when the licensed staff failed to properly document the residents' use of PRN (as needed) oxygen (O2) for three of four residents reviewed (Resident 1-3), and in addition the facility failed to ensure oxygen was administered with a physician's order for Resident 4. Residents Affected - Some These failures had the potential to result in inconsistent assessments and respiratory care interventions and increased the potential risk for changes in the resident ' s respiratory status to go untreated. Findings: On March 27, 2023, at 12:50 p.m., an unannounced visit was conducted at the facility for a quality of care concern. On March 27, 2023, at 1:15 p.m., Resident 2 was observed lying in bed. Oxygen was observed via nasal cannula (NC-a thin plastic tube used to deliver oxygen through the nose) at 3 liters per minute (L/m). Resident 2 stated he wore the oxygen continuously. On March 27, 2023, at 1:23 p.m., Resident 3 was observed sitting in a wheelchair watching television. Resident 3 was observed with oxygen at 3L/m via NC connected to an oxygen tank on the back of his wheelchair. Resident 3 stated he used the oxygen continuously. On March 27, 2023, at 1:25 p.m., Resident 4 was observed sitting on the edge of the bed. Resident 4 was observed with oxygen at 2L/m via NC. Resident 4 stated she used the oxygen continuously since admission to the facility and even took an oxygen tank with her to therapy. On March 27, 2023, Resident 1 ' s record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included acute respiratory failure (sudden impairment in breathing), congestive heart failure (CHF-heart condition were the heart does not pump blood adequately), pneumonia (lung infection), and atrial fibrillation (irregular heart rhythm). Review of Resident 1 ' s Physician Order Summary indicated, .OK to titrate O2 at 2-4 L/min via nasal cannula PRN to keep O2 SAT (saturation-the amount of oxygen in the blood) .> (greater than) 92% . dated March 12, 2022. Review of Resident 1 ' s Skilled Charting indicated the following: (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 555365 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Terrace Care Center 11162 Palm Terrace Lane Riverside, CA 92505 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)