Health inspection·May 25, 2023

F 0684 indicated Resident 10 had a BIMS (Brief Interview of Mental Status) score of 15 (cognitively intact). Level of Harm - Minimal harm or potential for actual harm A further review of Resident 10's record indicated there was no documented evidence the skin discoloration on Resident 10's right elbow was identified, assessed, and monitored by the facility. Residents Affected - Some On May 25, 2023, at 1:48 p.m., Resident 10 was concurrently observed with Licensed Vocational Nurse (LVN) 1. LVN 1 stated Resident 10 had a dark purple discoloration on the right inner elbow. She stated she was not aware of any skin discolorations to the right inner elbow for Resident 10 and it was not reported to her. Resident 10's record was concurrently reviewed with LVN 1. She stated there was no documentation of Resident 10's discoloration on the right inner elbow. LVN 1 further stated the discolorations on the right inner elbow of Resident 10 should have been identified, assessed, monitored, and referred to the physician for further evaluation and treatment. 2. On May 24, 2023, at 8:58 a.m., Resident 32 was observed sitting down in his wheelchair, awake, and alert. Resident 32 was observed to have multiple scattered dark purple skin discolorations on both posterior hands approximately measuring two cm by two cm. In a concurrent interview with Resident 32, he was not able to provide information on how he sustained the discolorations on his hands. Resident 32 further stated that he was on blood thinner medication which could cause him to bruise easily. On May 25, 2023, Resident 32's record was reviewed. Resident 32 was admitted to the facility on [DATE], with diagnoses which included respiratory failure, abnormalities of gait and mobility, and muscle weakness. A review of Resident 10's physician 's orders, dated August 29, 2022, indicated, .Monitor for s/s of bleeding every shift .while on Eliquis (medication use to prevent blood clot in older adults) .every shift . A review of Resident 32's History and Physical Examination, dated May 5, 2023, indicated Resident 32 had the capacity to understand and make decisions. A review of Resident 32's care plan, dated May 8, 2023, indicated, .AT RISK FOR BRUISING AND BLEEDING RELATED TO ANTICOAGULANT (medication to prevent blood clots) THERAPY .Monitor/document/report to MD (medical doctor) PRN (as needed) s/sx (signs and symptoms) of anticoagulant complications .bruising . A further review of Resident 32's record indicated there was no documented evidence the skin discoloration on Resident 32's bilateral hands were identified, assessed, and monitored by the facility. On May 25, 2023, at 1:32 p.m., an interview and concurrent record review with LVN 1 was conducted. LVN 1 stated she was not aware of any discolorations to the bilateral hands of Resident 32. LVN 1 stated there was no documentation of Resident 32's discolorations on both hands. She stated any new skin discoloration should be assessed, monitored, and referred to the physician for further evaluation and treatment once it was identified. 3. On May 23, 2023, at 2:13 p.m., Resident 44 was observed sitting down in the wheelchair, awake, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555365 If continuation sheet Page 2 of 10 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 05/25/2023 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm and alert. Resident 44 was observed to have one linear purplish discoloration on the right forearm approximately measuring three cm by 0.5 cm., and multiple scattered pink to purple round skin discolorations with various shape and size from the left elbow to the left hand. In a concurrent interview with Resident 44, he stated he did not know what caused the discoloration. He further stated, I guess I must have bumped it somewhere. Residents Affected - Some On May 25, 2023, Resident 44's record was reviewed. Resident 44 was admitted to the facility on [DATE], with diagnoses which included spinal stenosis (narrowing of the spinal canal in the lower part of the back), heart disease, and myocardial infarction (heart attack). A review of Resident 44's History and Physical Examination, dated January 31, 2023, indicated Resident 44 could make needs known but could not make medical decisions. A review of Resident 44's physician's order, dated March 10, 2023, indicated, .Monitor for s/s of bleeding every shift .Aspirin use .every shift . A review of Resident 44's care plan, dated February 17, 2023, indicated, . On Aspirin .will be free from discomfort or adverse reactions related to anticoagulant use .Daily skin inspection. Report abnormalities to the nurse .Monitor/document/report to MD PRN s/sx of anticoagulant complications .bruising . A further review of Resident 44's record indicated there was no documented evidence the skin discolorations on Resident 44's bilateral upper extremities were identified, assessed, and monitored by the facility. On May 25, 2023, at 1:48 p.m., an interview with LVN 1 was conducted. She stated she would conduct daily assessment of the resident's overall skin condition during wound care, and a weekly full head to toe skin assessment for all residents. Resident 44 was concurrently observed with LVN 1. LVN 1 stated resident had one linear purple discoloration on the right forearm and multiple scattered pink to purple round skin discolorations from the left elbow to the left hand. Resident 44's record was concurrently reviewed with LVN 1. She stated there was no documentation of Resident 44's discoloration on his bilateral upper extremities. LVN 1 further stated the skin discolorations for Resident 44 should have been assessed, monitored, and referred to the physician for further evaluation and treatment. On May 25, 2023, at 2:13 p.m., an interview with the Assistant Director of Nursing (ADON) was conducted. She stated the licensed nurses would check for any new skin condition daily during wound care and during scheduled shower days for residents. In addition, the licensed nurses should conduct a full body skin assessment weekly for all residents. In a concurrent record review with the ADON, she was not able to provide any documentation of the skin discolorations noted for Residents 10, 32, and 44. The ADON stated the skin discolorations noted for Residents 10, 32, and 44 should have been identified, monitored, and referred to the physician for further evaluation and treatment. The facility's policy and procedure titled, Skin Management System, dated February 2, 2023, was reviewed. The policy indicated, .Residents will have ongoing head to toe assessment done weekly, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555365 If continuation sheet Page 3 of 10 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 05/25/2023 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm incorporated into the LN (licensed nurse). Weekly Summary review by the licensed nursing staff .CNA's will complete a body shower Check Sheet daily on every resident, and turn it in to the charge nurse for possible follow up of any new skin concerns . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555365 If continuation sheet Page 4 of 10 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 05/25/2023 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)

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 humidifier was changed according to their facility policy, for one of one resident reviewed for oxygen (Resident 35). Residents Affected - Few This failure had the potential for Resident 35 to have a humidifier which was not working properly and may result in the decline of Resident 35's respiratory status. Findings: On May 22, 2023, at 11:28 a.m., Resident 35 was observed lying in bed while receiving oxygen at two liters per minute (LPM - unit of measurement) via a nasal cannula (NC - tubing in the nose to provide oxygen) with the date on the humidifier tubing of April 30, 2023. Resident 35 was verbal but not interviewable. On May 24, 2023, Resident 35's record was reviewed. Resident 35 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD - a lung disease). A review of the Physician Orders, dated April 21, 2023, indicated the following: - .CHANGE OXYGEN TUBING WEEKLY every day shift every Sun (Sunday) .; - .CONTINUOUS OXYGEN AT 2L/MIN VIA NASAL CANNULA/MASK TO KEEP OXYGEN SATURATION ABOVE 90% (percent) every shift .; and - .MONITOR FOR SOB (shortness of breath) WHILE LYING FLAT D/T (due to) COPD every shift . On May 25, 2023, at 1:34 p.m., an additional observation and concurrent interview was conducted with the Infection Preventionist (IP). She stated according to the facilities policy the humidifier sticker should be dated and replaced every seven days or as needed. On May 25, 2023, at 1:51 p.m., an interview was conducted with the Director of Staff Development (DSD). He stated the humidifier sticker should have been changed and dated every seven days on Sundays. He stated the resident may have been in room [ROOM NUMBER]A and the sticker on the humidifier should have indicated the change to show Sunday, May 21, 2023, as indicated on the oxygen tubing. The facility policy and procedure titled, Oxygen Equipment, revised February 2023, was reviewed. The policy indicated, .It is the policy of this facility to maintain all oxygen therapy equipment in a clean and sanitary manner and to use disposable pre-filled humidifiers .Pre-filled humidifiers, when used, are to be dated and replaced every 7 days, or according to manufacturer recommendation, or as needed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555365 If continuation sheet Page 5 of 10 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 05/25/2023 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure pharmacy services provided to the residents met their needs when: 1. One medication was attempted to be administered to one resident (Resident 160), that was labeled with another resident's name; 2. The facility along with the Consultant Pharmacist (CP) did not develop and implement policy and procedures for safe use of compounded sterile preparations (CSPs - preparing medication in an environment free from bacteria, viruses, or any other potentially infectious microorganisms) that included education and competency assessment of the facility nursing staff related to intravenous (IV - into the vein) compounding; and 3. The facility's CP was not aware of the presence of potent long-acting narcotic transdermal (applied on the skin) patches that were not considered for emergency use in the facility's Emergency Kit (EKIT, a kit containing emergency medication supplies for use when time is of the essence). These had the potential for resident receiving inaccurate, ineffective, non-sterile medications. Findings: 1. On May 23, 2023, at 8:40 a.m., during a medication pass observation conducted with Licensed Vocational Nurse (LVN) 50, she was observed to prepare medications for Resident 160 which included albuterol (medication used for shortness of breath and/or wheezing) oral hand-held inhaler labeled with the name of Resident 25. LVN 50 was asked to stop just as the medication was about to be administered to Resident 160. In a concurrent interview with LVN 50, she acknowledged the prescription label on the manufacturer box had the resident's name that was different than the resident that was about to be given the medication. On May 23, 2023, Resident 160's medical record was reviewed, and it indicated the resident was admitted on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD - lung disease that blocks airflow and makes it hard to breathe). There was a physician order, dated May 8, 2023, for Ventolin (brand name for albuterol) inhalation aerosol solution with the instruction to give the resident one puff to be inhaled by mouth every 12 hours related to COPD. On May 23, 2023, Resident 25's medical record was reviewed, and it indicated the resident had a physician order on December 14, 2022, for the same medication, albuterol, to be given to the resident with the direction, two puffs inhaled orally every four hours as needed for shortness of breath and/or wheezing. On May 23, 2023, at 2:33 p.m., during an interview with LVN 50, she acknowledged the mistake and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555365 If continuation sheet Page 6 of 10 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 05/25/2023 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)

F 0755 stated, I don't know how I missed that. Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure titled, Six Rights of Medication Administration, revised February 2023, indicated, .It is the policy of this facility to ensure that the six rights of medication administration are followed in order to ensure safety and accuracy of administration .The six rights of medication administration are as follows in order to ensure safety and accuracy of administration .Right Resident - Resident is identified prior to medication administration . Residents Affected - Few A review of the undated facility's policy and procedure titled, Medication Administration, indicated, .Medications provided for one resident are not to be used for another resident . 2. On May 23, 2023, at 1:23 p.m., during an inspection of the medication room in Nursing Station 1 with the Registered Nurse Supervisor (RNS), there was a medication refrigerator containing three sets of TPN (total parenteral nutrition - a complete nutrition given via vein to the resident unable to eat) and two injectable vials of Infuvite (vitamin supplement) labeled for Resident 12. The TPNs were labeled, This medication has been compounded by the Pharmacy. The pharmacy label associated with the Infuvite vials indicated: Mix each bag (of TPN) with 10 ml (milliliter, unit of measurement) Infuvite (blue and white) daily . On May 23, 2023, Resident 12's medical was reviewed. Resident 12 was admitted to the facility on [DATE], with diagnoses which included, malnutrition, hyperalimentation (TPN), muscle weakness, adult failure to thrive. There was a physician order, dated May 12, 2023, for TPN formula for the resident with the direction to mix each bag of TPN with 10 ml of Infuvite (blue and white) and infuse at a rate of 90 ml per hour from 8 a.m. to 2 p.m. daily. On May 24, 2023, at 3:45 p.m., in an interview, the Pharmacist-In- Charge (PIC) at the dispensing pharmacy in which the TPNs were compounded and delivered to the facility, did not indicate the mixing of the two injectable vials of Infuvite into the TPN was considered compounding. On May 25, 2023, at 9:15 a.m., in an interview, the CP stated he was not aware mixing of the vials of infuvite into the TPN was considered compounding, The CP stated he reviewed the pharmacy policy and procedure and did not find any policies that addressed the nursing education on IV compounding. On May 25, at 2:21 p.m., in an interview, the RN Supervisor (RNS) stated mixing the vials of Infuvite into the TPN was considered compounding. The RNS stated she was not provided education on IV compounding by the CP. On May 25, 2023, a review of the facility document titled, Nursing Skills Checklist, General Competencies, for the RNS, dated August 19, 2022, did not include assessment of IV compounding as a part of the nursing competencies. A review of the facility's policy and procedure titled, Pharmacist, Services of a Licensed, dated February 2023, indicated, .It is the policy of this facility to employ or obtain the services of a licensed pharmacist to provide consultation on all aspects of pharmacy services in the facility .The pharmacist is responsible for helping the facility obtain and maintain timely and appropriate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555365 If continuation sheet Page 7 of 10 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 05/25/2023 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm pharmaceutical services that support residents' healthcare needs, that are consistent with current standards of practice, and that meet state and federal requirements .Develop intravenous (IV) therapy procedures if used within the facility may include determining competency of staff, facility-based IV admixture procedures that address sterile compounding, dosage calculations, IV pump use, and flushing procedures . Residents Affected - Few The U.S. Pharmacopeial Convention (USP) is a scientific nonprofit organization that sets standards for the identity, strength, quality, and purity of medicines, food ingredients, and dietary supplements manufactured, distributed, and consumed worldwide. USP's drug standards are enforceable in the United States by the Food and Drug Administration. According to the USP, Compounding: The preparation, mixing, assembling, altering, packaging, and labeling of a drug, drug-delivery device, or device in accordance with a licensed practitioner's prescription, medication order, or initiative based on the practitioner/patient/ pharmacist/compounder relationship in the course of professional practice. Compounding includes the following .Reconstitution or manipulation of commercial products that may require the addition of one or more ingredients . USP Chapter <797> provides procedures and requirements for compounding sterile preparations (CSPs). General Chapter <797> describes conditions and practices to prevent harm to patients that could result from microbial contamination, excessive bacterial endotoxins, variability in intended strength, unintended chemical and physical contaminants, and ingredients of inappropriate quality in compounded sterile preparations. According to the USP, .Low-Risk Level CSPs .The compounding involves only transfer, measuring, and mixing manipulations using not more than three commercially manufactured packages of sterile products and not more than two entries into any one sterile container or package (e.g., bag, vial) of sterile product or administration container/device to prepare the CSP . The immediate-use provision is intended only for those situations where there is a need for emergency or immediate patient administration of a CSP. Such situations may include cardiopulmonary resuscitation, emergency room treatment, preparation of diagnostic agents, or critical therapy where the preparation of the CSP under conditions described for Low-Risk Level CSPs subjects the patient to additional risk due to delays in therapy . Immediate-use CSPs are exempt from the requirements described for Low-Risk Level CSPs only when all of the following criteria are met .The compounding process involves simple transfer of not more than three commercially manufactured packages of sterile nonhazardous products or diagnostic radiopharmaceutical products from the manufacturers' original containers and not more than two entries into any one container or package (e.g., bag, vial) of sterile infusion solution or administration container/device . 3. On May 23, 2023, at 1:23 p.m., during an inspection of the medication room in Nursing Station 1 with the Registered Nurse Supervisor (RNS), there was an EKIT labeled, Narcotic EKIT Scheduled II, with the following medications inside: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555365 If continuation sheet Page 8 of 10 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 05/25/2023 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few - Two Duragesic (fentanyl) (potent narcotic pain medication) 25 mcg/hr (microgram per hour) transdermal patch; and - Two Duragesic (fentanyl) 50 mcg/hr transdermal patch. On May 23, 2023, at 3:30 p.m., during an interview with the CP, he stated fentanyl patches did not provide immediate relief from pain and would not be effective in emergency situations. On May 24, 2023, at 11:10 a.m., the CP agreed fentanyl patches were not considered emergency medications. The manufacturer's prescribing information for fentanyl transdermal patches indicated, .Following fentanyl transdermal system application, the skin under the system absorbs fentanyl, and a depot of fentanyl concentrates in the upper skin layers. Fentanyl then becomes available to the systemic circulation. Serum fentanyl concentrations increase gradually following initial fentanyl transdermal system application, generally leveling off between 12 and 24 hours and remaining relatively constant, with some fluctuation, for the remainder of the 72-hour application period . The facility's policy and procedure titled, Pharmacist, Services of a Licensed, dated February 2023, indicated, .It is the policy of this facility to employ or obtain the services of a licensed pharmacist to provide consultation on all aspects of pharmacy services in the facility .The pharmacist is responsible for helping the facility obtain and maintain timely and appropriate pharmaceutical services that support residents' healthcare needs, that are consistent with current standards of practice, and that meet state and federal requirements . The state law and regulations did not allow inclusion of transdermal patches in the facility's emergency supplies (EKITs). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555365 If continuation sheet Page 9 of 10 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 05/25/2023 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure kitchen utensils were clean and in safe operating conditions. Residents Affected - Some This failure had the potential to result in cross contamination and foodborne illness (stomach illness acquired from ingesting contaminated food) in a medically vulnerable population of 66 residents who consumed food from the kitchen. Findings: On May 22, 2023, at 10:30 a.m., during the initial kitchen tour with the Dietary Supervisor (DS), the following kitchen utensils stored in a closed clear container located underneath the preparation table were observed: 1. One rubber spatula was observed cracked and chipped; 2. One plastic scoop was observed with brown residue; 3. One metal scraper was observed with brown residue spots; 4. One plastic measuring scoop was observed with brown sticky residue. In a concurrent interview with the DS, she stated all kitchen utensils identified were ready for use to prepare food in the kitchen. She stated all kitchen utensils should be free from any residue. She also stated all utensils should not be cracked or chipped and should have been discarded. The DS stated any residue or cracked/chipped on the kitchen utensils could harbor bacteria which could lead to cross contamination of food and compromising the overall health condition of the residents in the facility. According to the 2022 Federal Food Code, food-contact surfaces are to be smooth, free of breaks, open seems, cracks, inclusions and are to be clean to sight and touch. The policy and procedure titled, Equipment Maintenance, dated February 2, 2023, was reviewed. The policy indicated, .It is the policy of this facility to establish procedures for routine and non-routine care of equipment and to ensure that equipment remains in good working order for resident and staff safety . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555365 If continuation sheet Page 10 of 10