Health inspection·May 16, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated food should be served at the same time per table. LVN 1 stated the facility should have been more organized when serving food in the dining room. LVN 1 further stated, It's a dignity issue. On May 15, 2025, at 9:12 a.m., during an interview with the Director of Nursing (DON), the DON stated she expected the staff to serve the tray at the same time and no one should be left out. The DON stated the staff should follow the system where they have a list of residents who will eat at a table in the dining room. The DON further stated if the system would not be followed, residents would feel upset because they were not served food as the others at the same time. A review of the facility's policy and procedure titled, Dignity and Privacy, dated January 2025, indicated, .It is the policy of this facility that all residents be treated with kindness, dignity and respect . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555365 If continuation sheet Page 2 of 20 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 05/16/2025 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 0558 Reasonably accommodate the needs and preferences of each resident. 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 call lights were answered in a timely manner, for six out 68 residents (Residents 10, 27, 37, 55, 56 and 163). Residents Affected - Some This failure had the potential for the residents' emotional, psycho-social, and optimal physical well-being to not be met. Findings: 1. On May 12, 2025, at 9:55 a.m., an interview was conducted with Resident 10 in her room. Resident 10 stated it would take time for the staff to answer her call light during the morning shift. Resident 10 stated she had waited an hour for someone to come during the night shift and it was frustrating. A review of Resident 10's medical record indicated she was admitted on [DATE], with diagnoses which included surgical aftercare following skin and tissue infection. A review of Resident 10's History and Physical, dated April 3, 2025, indicated Resident 10 had the capacity to understand and make decisions. A review of Resident 10's Minimum Data Set (MDS - an assessment and screening tool), dated April 6, 2025, indicated a BIMS (Brief Interview for Mental Status) score of 14 which indicated cognitively intact. On May 13, 2025, at 9:20 a.m., an interview with Certified Nursing Assistant (CNA) 1 was conducted. CNA 1 stated she had Resident 10 complained about long waits for the call light at night. CNA 1 stated she reported those complaints to the charge nurse. On May 15, 2025, at 8:40 a.m., an interview with Resident 10 was conducted. Resident 10 stated the staff would sometimes answer the call light and say they would be right back and the staff did not return. Resident 10 stated many times it was a simple request for another blanket or for more water. Resident 10 further stated it did not make her feel good when the staff would walk away because the resident could take a minute or two to remember what she needed due to her memory problems. 2. On May 12, 2025, at 8:30 a.m., an observation and interview with Resident 55 was conducted. Resident 55 stated sometimes he had to wait for someone to answer the call light at different times. Resident 55 stated he had waited longer than 20 minutes, and he would prefer if the staff could come sooner. On May 15, 2025, a review of Resident 55's medical record indicated Resident 55 was admitted on [DATE], with diagnoses which included fractured (broken) lumbar vertebrae (lower back spine bone ), multiple right sided rib fractures, compression fracture thoracic vertebrae (fracture of the spine bones in mid-back) from a fall at home. A review of Resident 55's Initial History and Physical, dated April 24, 2025, indicated Resident 55 had the capacity to understand and make decisions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555365 If continuation sheet Page 3 of 20 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 05/16/2025 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 0558 Level of Harm - Minimal harm or potential for actual harm A review of Resident 55's MDS, dated April 25, 2025, indicated Resident 55 had a score of 14 which indicated cognitively intact. On May 13, 2025, at 10 a.m., an interview with CNA 2 was conducted. CNA 2 stated Resident 55 had informed her he had long waits at night because he felt anxious. Residents Affected - Some On May 15, 2025, at 9:10 a.m. a follow up interview with Resident 55 was conducted. Resident 55 stated he becomes frustrated and anxious when he had to wait more than 30 minutes for a nurse to come. On May 16. 2025, at 8 am., an interview was conducted with the Director of Nursing (DON). The DON stated the facility's goal was to answer call lights in less than 5 minutes. The DON stated it was the expectation for everyone to answer call lights, including administration, so residents should never have to wait long. The DON stated she had received complaints from residents about long call light wait times, especially at night. The DON further stated when the residents' call lights were not answered promptly it could increase the possibility of skin integrity breakdown and the risk of resident's falls. 3. On May 12, 2025, at 6:06 a.m., during an interview with Resident 163, Resident 163 stated he waited a long time for the call light to get answered and felt he was not serviced fast enough. Resident 163 stated he had waited as long as 30 minutes on some occasion. Resident 163 further stated he had complained about it, nothing had been done and it frustrated him. On October 14, 2025, Resident 163's record was reviewed. Resident 163 was admitted to the facility on [DATE], with diagnoses which included urinary tract infections (infection in the bladder), muscle weakness, and dysphagia (difficulty swallowing). A review of Resident 163's MDS, dated April 4, 2025, indicated Resident 163 had a BIMS score of 13 (cognitively intact), and Resident 163 required partial/moderate assistance with toileting hygiene and substantial/maximal assistance with shower/bathe self, personal hygiene, toilet transfer and tub/shower transfer. A review of Resident 163's History and Physical, dated May 8, 2025, indicated Resident 163 had the capacity to make decisions. On May 15, 2025, at 3:55 p.m., during an interview with Registered Nurse (RN) 1, RN 1 stated the call lights would beep and make an audible sound. RN 1 stated the staffing during the night shift was not good and had received complaints regarding the call lights not being answered timely during the afternoon shift (3 p.m. to 11 p.m.). RN 1 further stated the Administrator, Social Services and the Director of Nursing were aware of the complaints about the call lights. RN 1 also stated if residents were left soiled it could their skin integrity and their dignity. RN 1 further stated the expectation was for the call lights to be answered in five to 10 minutes and residents should be checked. 4. On May 12, 2025, at 4:04 p.m., during an interview with Resident 37, Resident 37 stated he had concerns on the night shift with staff answering the call light. Resident 37 stated, it takes 15 to 20 minutes for staff to answer the call light. Resident 37 stated normally he would call for help to get in and out the bathroom and help to get back in bed. On May 14, 2025, Resident 37's record was reviewed. Resident 37 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (lung diseases that block air flow), muscle weakness, and abnormalities of gait and mobility (abnormal walking). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555365 If continuation sheet Page 4 of 20 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 05/16/2025 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 37's History and Physical, dated January 24, 2025, indicated Resident 37 had the capacity to understand and make decisions. A review of Resident 37's MDS, dated April 26, 2025, indicated Resident 37 had a BIMS score of 15 (cognitively intact), and Resident 37 required supervision or touching assistance with toileting hygiene, shower/bathing self/ and toilet transfer. 5. On May 13, 2025, at 10:17 a.m., during an interview with Resident 27, Resident 27 stated on the night shift, it sometimes took an hour for staff to answer the call light. Resident 27 stated it mostly happened on the night shift. Resident 27 also stated he knew the staff was busy, so he tried to catch them when they walked through the hallways. Resident 27 stated he reported his concern to staff, but no one has responded about it. On May 14, 2025, Resident 27's record was reviewed. Resident 27 was admitted to the facility on [DATE], with diagnoses which included spinal stenosis (space inside bones of the spine too small), obstructive and reflux uropathy (blockage and backflow of urine from the bladder), and benign prostatic hyperplasia (enlargement of the prostate). A review of Resident 27's History and Physical, dated February 20, 2025, indicated Resident 27 had the capacity to understand and make decisions. A review of Resident 27's MDS, dated April 12, 2025, indicated Resident 27 had a BIMS score of 15 (cognitively intact), and Resident 27 required supervision or touching assistance with toileting hygiene, shower/bathing self/and lower body dressing and toilet transfer. 6. On May 15, 2025, at 8:14 a.m., during an interview with Resident 56, Resident 56 stated she gets regular assistance to the bathroom except on the night shift. Resident 56 stated that when she feels the urge to go to the bathroom, she would use the call light but she had waited 20-30 minutes for the call light to get answered. Resident 56 further stated it was frustrating. On May 14, 2025, Resident 56's record was reviewed. Resident 56 was admitted to the facility on [DATE], with diagnoses which included orthopedic (bone) care, osteoarthritis (common form of arthritis), parkinsonism (brain condition that causes slow movement) and difficulty walking. A review of Resident 56's History and Physical, dated April 22, 2025, indicated Resident 56 had the capacity to understand and make decisions. A review of Resident 56's MDS, dated April 26, 2025, indicated Resident 56 had a BIMS score of 10 (moderate cognitive impairment), and Resident 56 was dependent for toilet hygiene, lower body dressing, required substantial/maximal assistance with tub and shower transfer, and partial/moderate assist with toilet transfer. On May 16, 2025, at 7:47 a.m., during an interview with the Director of Nursing (DON), the DON stated she expected all staff to answer the call lights in less than five minutes. The DON stated it was the expectation that everyone can answer the call lights, including administration, so residents should never have a long wait. The DON stated she had received complaints from residents about long call light wait times, especially at night. The DON further stated when resident's call lights were not ansered promptly, it could increase the possibility of skin integrity breakdown, and the risks of resident falls. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555365 If continuation sheet Page 5 of 20 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 05/16/2025 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the facility's policy and procedure titled, Call Light, dated January 2025, indicated, .It is the policy of this facility to provide the resident a means of communication with nursing staff .Procedures: answer the light/bell within a reasonable time. A review of the facility's Job Description titled, Certified Nursing Assistant, dated December 17, 2021, indicated, .The primary purpose of your job position is to provide each of your assigned residents with routine daily nursing care and services, in accordance with the resident's assessment and care plan . check each resident routinely to ensure that his/her personal care needs are being met .Answer resident calls promptly. A review of the facility's policy and procedure titled, Dignity and Privacy, dated January 2025, indicated, .It is the policy of this facility that all residents be treated with kindness, dignity and respect . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555365 If continuation sheet Page 6 of 20 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 05/16/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a comfortable homelike environment, for two of two residents reviewed for environment (Residents 48 and 164), when peeled paint were observed on the wall at the side of Residents 48 and 164's bed and at the bathroom door frame of room [ROOM NUMBER]. These failure had the potential for residents not to experience a comfortable and inviting stay while in the facility. Findings: On May 12, 2025, at 3:56 p.m., Resident 164 was observed sitting up in his bed. A patchy area of peeled paint was observed on the wall at the right side of Resident 164's bed. On May 13, 2025, at 9:43 a.m., Resident 27's was observed sitting in her wheelchair next to her bed. Observed peeled paint on the side of the wall next to Resident 27's bed. On May 15, 2025, at 12:54 p.m., a concurrent observation with the Maintenance Supervisor (MS) was conducted in the bathroom in room [ROOM NUMBER]. Observed areas of peeled paint at the at the door frame in the bathroom. On May 15, 2025, at 4:04 p.m., during an interview with the Maintenance Supervisor (MS). The MS stated he was responsible for keeping the building safe. The MS also stated he had to keep the rooms painted and clean. The MS further stated the walls should be fixed, smooth, and painted so it would look like a homelike environment. On May 15, 2025, 4:21 p.m., the Administrator (ADM) stated the walls should be painted and fixed, further stated, we want it to have a feeling of looking like home. A review of the facility's policy and procedure titled, Homelike Environment, dated January 2024, indicated, .It is the policy of this facility to encourage and provide opportunities for each resident to occupy an area reflecting his/her interests, family, or is made homelike by choosing special decorations .Purpose: To provide a homelike environment for residents . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555365 If continuation sheet Page 7 of 20 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 05/16/2025 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS- a clinical assessment tool) was accurately coded, for one of one resident reviewed for hearing (Resident 214). Residents Affected - Few This failure had the potential to cause inaccuracy in identifying Resident 214's care and support needs, and cause delay of needs being met. Findings: On May 14, 2025, Resident 214's record was reviewed. Resident 214 was admitted to the facility on [DATE], with diagnoses which included hearing loss of the right ear. A review of Resident 214's inventory sheet dated April 24, 2025, indicated, .1 hearing aide (L) . A review of Resident 214's Initial admission Record, dated April 24, 2025, indicated Resident 214 had a moderate difficulty in hearing. A review of Resident 214's MDS, dated April 28, 2025, indicated Resident 214 was not using a hearing aid and the hearing ability was adequate. A review of Resident 214's Social Service Summary, dated April 29, 2025, indicated, .She wears a left hearing aide only and its here at the facility . On May 14, 2025, at 9:23 a.m., during a concurrent interview and record review with MDS Nurse, the MDS Nurse stated Resident 214 was admitted to the facility on [DATE], with a hearing aid in her left ear. The MDS Nurse stated Resident 214 was moderately impaired in hearing and should have been reflected on MDS section B. The MDS Nurse further stated the MDS assessment was not accurate. On May 15, 2025, at 9:36 a.m., the Director of Nursing (DON) was interviewed. The DON stated the MDS assessment for Resident 214 should have been coded as moderately impaired with hearing and it should have been reflected to the actual status of the resident. The DON further stated Resident 214 needs, care, and support would not be met if the MDS assessment would not be accurately coded. A review of the facility's policy and procedure titled, Accuracy of Assessment, dated January 2024, indicated, .It is the policy of this facility to ensure that the assessment accurately reflect the resident's status .An MDS Nurse must conduct or coordinate each assessment with the appropriate participation of health professionals . A review of the facility's manual version 3.0 titled, RESIDENT ASSESSMENT INSTRUMENT (RAI), dated October 2024, indicated, .The purpose of this manual is to offer clear guidance how to use the Resident Assessment Instrument (RAI) correctly and effectively to help provide appropriate care .the care plan becomes each resident's unique path toward achieving or maintaining their highest practical level of well-being . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555365 If continuation sheet Page 8 of 20 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 05/16/2025 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 0685 Assist a resident in gaining access to vision and hearing services. 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 an audiology (healthcare specialists in hearing loss, hearing tests, hearing aid selection) consultation was provided, for one of one resident reviewed for hearing (Resident 214). Residents Affected - Few This failure had the potential to result in Resident 214 not receiving the audiology services needed to maintain her highest practicable level of well-being. Findings: On May 12, 2025, at 2 p.m., during a concurrent observation and interview with Resident 214 in the hallway, Resident 214 was observed staring at Certified Nursing Assistant (CNA) 3, while talking to her. Resident 214 stated she was using one hearing aid in her left ear and she was unable to hear CNA 3. Resident 214 further stated, Huuhhh? On May 12, 2025, at 2:20 p.m., during an interview with CNA 3, CNA 3 stated Resident 214 had left hearing aide and still was not able to hear. CNA 3 stated Resident 214's left hearing aide was not working properly. On May 15, 2025, Resident 214's record was reviewed. Resident 214 was admitted to the facility on [DATE], with diagnoses which included hearing loss in the right ear. A review of Resident 214's Initial admission Record, dated April 24, 2025, indicated Resident 214 had a moderate difficulty in hearing. A review of Resident 214's Order Summary, dated April 24, 2025, indicated, .Audiologist eval (evaluation) and treat PRN (as needed) . A review of Resident 214's Inventory of Personal Effects, dated April 24, 2025, indicated Resident 214 had left hearing aide. A review of Resident 214's Social Service Summary, dated April 29, 2025, indicated, .She wears a left hearing aide only and its here at the facility . A review of Resident 214's Care Plan Report, dated April 25, 2025, indicated, .At risk for a communication problem r/t (related to) HOH (hard of hearing) R (right) ear .Refer to Audiology for hearing consult as ordered . A review of Resident 214's History and Physical, dated May 7, 2025, indicated Resident 214 was mentally incapable of understanding. On May 14, 2025, at 9:10 a.m., during a concurrent interview and record review with Registered Nurse (RN) 1, RN 1 stated Resident 214 was admitted with a left hearing aid and was recorded in Resident 214's inventory sheet on April 24, 2025. RN 1 stated the left hearing aid was not working for Resident 214, so she should be referred to an audiologist. RN 1 further stated if Resident 214 would be unable to hear properly, her mood could be affected, and she could become upset and frustrated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555365 If continuation sheet Page 9 of 20 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 05/16/2025 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 0685 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On May 14, 2025, at 9:46 a.m., during an interview with the Social Service Director (SSD), the SSD stated Resident 214 should have been referred to an ear doctor to address the hearing problem. The SSD further stated Resident 214's self-esteem could be affected and cause her to feel frustrated and irritated if Resident 214 would not provided audiology services. On May 15, 2025, at 9:36 a.m., during an interview with the Director of Nursing (DON), the DON stated Resident 214 should have been referred to an audiologist to check the hearing aid and her hearing condition. The DON further stated if Resident 214 would not seen by audiologists, Resident 214 would potentially feel frustrated when she interacts with staff and other residents. A review of the facility's policy and procedure titled, Dental, Optometry, and Audiology Evaluations, dated January 2025, indicated, .It is the policy of this facility that Social Services staff will coordinate Dental, Optometry and Audiology evaluations for residents .Social services will maintain a system to monitor the dental, optometry and audiology evaluations . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555365 If continuation sheet Page 10 of 20 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 05/16/2025 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on interview and record review, the facility failed to ensure sufficient staff were provided to meet the needs of the residents when the facility did not meet the required or minimum of Actual Total CNA Direct Care Service Hours for CNA DHPPD (DHPPD - measure the numbers of hours of direct care given to residents in skilled nursing facility) of 2.4 hours for March 1, 2025, of 31 days reviewed and April 5, 2025, of 30 days reviewed. The failure to maintain a the required minimum CNA DHPPD hours had the potential to increase the resident's risk of fall and to meet residents' requests for assistance with activities of daily living. Findings: On May 14, 2025, a concurrent interview and record review of the facility's Census and Direct Care Service Hours Per Patient Day, was conducted with the Director of Staff Development (DSD). The DSD confirmed records of two days in March 2025 and April 2025, indicated the Actual Total CNA Direct Care Service Hours were below the required minimum of 2.4 hours. The Actual Total DCSH hours were below 2.4 hours (hrs) on the following dates: - March 1, 2025 (Saturday) 2.36 hrs (CNA DCSH); and - April 5, 2025 (Saturday) 2.32 hrs (CNA DCSH). On May 15, 2025, at 3 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated there had been a turnover of nightshift CNA's. The DON stated the facility's goal was to consistently meet mandated CNA hours. The DON further stated that when staffed with less than mandated hours, they could decrease resident safety and satisfaction in meeting their needs. A review of the facility's policy and procedure titled Nursing Services Staffing, Adequate, dated January 2025, indicated .this facility to provide sufficient numbers of staff .to provide care and services for all residents .in accordance with .facility assessment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555365 If continuation sheet Page 11 of 20 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 05/16/2025 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 0790 Provide routine and 24-hour emergency dental care for each resident. 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 a dental consultation was provided, for one of one resident reviewed for dental (Resident 24). Residents Affected - Few This failure had the potential to result in Resident 24 not to receive the dental services needed to maintain his highest practicable level of well-being. Findings: On May 12, 2025, at 11:38 a.m., during a concurrent observation and interview with Resident 23 in his room, Resident 24 was observed with some missing upper and lower teeth. Resident 24 stated he wanted to have dentures, and he was not seen by the dentist. Resident 24 further stated it was hard for him to chew solid food. On May 15, 2025, Resident 24's record was reviewed. Resident 24 was admitted to the facility on [DATE], with diagnoses which included facial weakness. A review of Resident 24's Order Summary, included a physician's order, dated July 9, 2022, indicated, .MAY HAVE DENTAL CONSULT WITH FOLLOW UP TREATMENT AS NEEDED . A review of Resident 24's Impressions Mobile Dentistry, dated February 28, 2024, indicated, Resident 24 had multiple missing teeth and root tips, and treatment was recommended as needed. A review of Resident 24's History and Physical Note, dated August 20, 2024, indicated Resident 24 was mentally capable of understanding. A review of Resident 24's Minimum Data Set (MDS - a resident assessment tool), dated April 5, 2025, indicated Resident 24 had a BIMS (Brief Interview of Mental Status) score of 15 which indicated cognitively intact. On May 14, 2025, at 10:07 a.m., during an interview with the Social Service Director (SSD), the SSD stated Resident 24 should have been referred to a dentist to have dentures. The SSD further stated Resident 24 would not be able to eat properly and could lead to weight loss if Resident 24 was not provided dental services. On May 15, 2025, at 9:31 a.m., during an interview with the Director of Nursing (DON), the DON stated she expected the nurses and SSD to follow facility's policy and procedure for dental services. The DON stated Resident 24 should have been referred to the dentist. The DON further stated, if Resident 24 would not receive dental services, he would not eat food properly and could lead to weight loss. On May 15, 2025, at 11:20 a.m., during an interview with the Facility Dentist (FD), the FD stated he received a dental referral from SSD, and he would check all the residents that were listed. The FD stated Resident 24 should have been seen right away to prevent complications. The FD further stated, I'm always available, and I come right away. A review of the facility's policy and procedure titled, Dental, Optometry, and Audiology (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555365 If continuation sheet Page 12 of 20 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 05/16/2025 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 0790 Level of Harm - Minimal harm or potential for actual harm Evaluations, dated January 2025, indicated, .It is the policy of this facility that Social Services staff will coordinate Dental, Optometry and Audiology evaluations for residents .Social services will maintain a system to monitor the dental, optometry and audiology evaluations . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555365 If continuation sheet Page 13 of 20 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 05/16/2025 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 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. 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, facility failed to provide assistive devices such as a plate divider (equipment to prevent food from falling off the plate), for one of three residents observed during mealtime (Resident 22). Residents Affected - Few This failure had the potential for Resident 22 to not meet the daily nutritional needs, which could lead to weight loss. Findings: On May 12, 2025, at 12:24 p.m., during a concurrent observation and interview with Resident 22 in the dining room, Resident 22 was observed scooping the food onto her plate, but the food fell off the plate. She stated the food was spilling out of the plate and the fork was unable to hold it. The bread and green veggies were observed on the floor. On May 12, 2025, at 12:29 p.m., during a concurrent observation ad interview was conducted with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 22 spilled the food on the side of the plate and on the floor. LVN 1 stated Resident 22 could eat by herself, a plate guard should have been provided to prevent food from spilling. On May 15, 2025, Resident 22's record was reviewed. Resident 22 was admitted to the facility on [DATE], with diagnoses which included Parkinson's disease (disorder that affects movement). A review of Resident 22's History and Physical, dated March 12, 2025, indicated Resident 22 was mentally capable of understanding. A review of Resident 22's Order Summary, dated March 10, 2025, indicated, .NAS (No added salt) diet MECHANICAL SOFT texture . On May 15, 2025, at 9:14 a.m., during an interview with the Director of Nursing (DON), the DON stated Resident 22 should have been evaluated and provided assistive eating devices. The DON further stated if Resident 22 was unable to eat the food properly, Resident 22 might not meet her nutritional needs, which could lead to weight loss. On May 15, 2025, at 11:00 a.m., during an interview with the Director of Rehabilitation (DOR), the DOR stated the nursing staff assigned in the dining room or direct staff that observed resident during meal time should referred to their department to evaluate any adaptive device needed for residents. The DOR further stated Resident 22 should have been referred for evaluation for adaptive device and should have been provided with plate divider. A review of the facility's policy and procedure titled, Adaptive Equipment for dining, dated January 2025, indicated, .It is the policy of this facility to provide adaptive equipment to residents as needed .An occupational therapist is recommended for evaluating needs .The divided plate is an excellent choice for all skilled level dining rooms . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555365 If continuation sheet Page 14 of 20 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 05/16/2025 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 Residents Affected - Many 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 food safety and sanitation practices were maintained in the kitchen according to standards of practice and facility policy, for 67 out 68 residents who eat food from the kitchen, when: 1. Four (4) large metal pans with food debris and dripping water on them were stored and stacked on top of each other on a bottom shelf; and 2. One 50-pound (lb- unit of measurement) bag of instant milk nonfat dry powder was found stored with an open tear in the bag, with food product seeping out and with clear tape covering it. These failures exposed residents' to contaminated food and unsanitary practices, which had the potential to place them at risk of developing a foodborne illness. Findings: 1. On May 12, 2025, at 7:04 a.m., a concurrent observation and interview was conducted with the Dietary Supervisor (DS) in the kitchen. There were three large metal pans, and one large metal perforated pan that had water and food debris on them observed dripping wet and stacked on top of each other and stored under the counter. The DS stated the pans were not clean and had debris on them. The DS also stated that the pans should not have food debris on them and should not be stacked and stored wet. The DS further stated the pans should be clean and dried before storing. On May 16, 2025, at 08:56 a.m., a telephone interview with Registered Dietitian (RD) 2 was conducted. RD 2 stated the expectation of the staff were not to stack and store wet dishes. RD 2 stated that the pans should not have been stored wet. RD 2 also stated the pans should have been stacked individually, then waited until dried and then put away. RD 2 further stated that she expected kitchen staff to identify dishes that had debris, rewashed, and dry properly before using them to cook. RD 2 stated there was the possibility of cross contamination which could make residents sick. According to the 2022 Federal Food Code, Section 4-601.11, titled Cleaning of Equipment and Utensils. Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils.(A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch . A review of the facility's policy and procedure titled, Dietary Services Dietary, Sanitation in, dated January 2025, indicated, .It is the policy that the food service area shall be maintained in a clean and sanitary manner .All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair . 2. On May 12, 2025, at 8:37 a.m., a concurrent observation and interview with the DS was conducted in the facility's outside kitchen storage for emergency food. One 50 lb bag of non fat dry powder instant milk was observed with an opened tear in the bag, and was covered with clear tape. In a concurrent interview with the DS, she stated the bag should not have a hole in it. The DS further stated pest could get inside and that would contaminate the food. On May 15, 2025, at 3:42 p.m., a concurrent interview and observation with RD 1 was conducted in the facility's outside kitchen storage for emergency food. RD 1 stated if the packaged food arrived (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555365 If continuation sheet Page 15 of 20 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 05/16/2025 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 Residents Affected - Many damaged the facility's process was to send it back. RD 1 stated if the packaged food was damaged at the facility, it should not be used and must be discarded. RD 1 further stated the food item could become contaminated and someone could get sick if the food was not sealed properly. According to the 2022 Federal Food Code, section 3-307.00 Miscellaneous Sources of Contamination, indicated, .Food shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 to 3-306. A review of the facility's policy and procedures titled, Food and Nutrition Services: Food, Dry Storage of, dated January 2025, indicated, .It is the policy of this facility that all non-perishable foods shall be stored utilizing methods which maximize nutrient retention, food appearance, and food quality .Dry goods (i.e. cereal and grains) .shall be stored according to the USDA Food Safety Information on Shelf-Stable Food Safety . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555365 If continuation sheet Page 16 of 20 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 05/16/2025 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 0880 Provide and implement an infection prevention and control program. 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 infection control practices were implemented when: Residents Affected - Some 1. For Resident 24, facility failed to conduct proper screening for the annual tuberculin skin test (TBtuberculosis [lung disease] test - screening to determine if someone infected with germs that cause tuberculosis); 2. For Resident 213, one 4,000 milliliters (ml - unit of measurement) incentive spirometer (device use to expand lungs) was observed not properly stored in a bag; and 3. For Resident 216, the Physical Therapist (PT) (healthcare provider who performs physical movement) did not wear personal protective equipment (PPE - equipment use to protect against infection or illness) when providing therapy to a resident requiring enhanced barrier precautions (EBP - an infection control intervention to reduce transmission of multidrug-resistant organisms [MDRO - bacteria that have become resistant to multiple antibiotics]). These failures had the potential to result in transmission of infection to an already vulnerable population of residents in the facility. Findings: 1. On May 14, 2025, at 3 p.m., during a concurrent interview and record review with the Infection Preventionist (IP), the IP stated he conducted surveillance of all immunizations which included TB screening to all residents. The IP stated the process of administering TB test included a two-step TB skin test to be administered upon admission of a resident, and a one-step TB skin test would be administered annually thereafter. The IP stated TB test would be read after three days for the result. The IP stated Resident 216's TB test was administered on July 8, 2024, and there was no reading of the TB test result after three days. The IP further stated if there was no reading, the TB test should should have been repeated to complete the annual TB screening. On May 15, 2025, at 9:25 a.m., during an interview with the Director of Nursing (DON), the DON stated she expected the IP to follow the facility's policy on annual TB screening for residents. The DON stated Resident 24's TB screening should have been readministered if the result was not read. The DON further stated the annual TB screening should have been implemented according to facility's tuberculosis control plan. A review of the facility's policy and procedure titled, Tuberculosis Control Plan, dated January 2025, indicated, .It is the policy of this facility that .Each resident admitted to this facility shall be screened for TB, as prescribed by the attending physician .a PPD skin test results, by Mantoux method is recommended and shall be documented on the medication sheet or a PPD form . 2. On May 12, 2025, at 8:30 a.m., during a concurrent observation and interview with Resident 213 in her room, Resident 213's incentive spirometer was observed placed on top of Resident 213's nightstand, and not in a bag. Resident 213 stated she placed the incentive spirometer on top of the nightstand table when not in use. Resident 213 stated she did not have a plastic bag container to use as storage for her incentive spirometer when not in use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555365 If continuation sheet Page 17 of 20 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 05/16/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On May 12, 2025, at 8:37 a.m., during a concurrent observation and interview with Registered Nurse (RN) 1, RN 1 stated Resident 213 should have a plastic container to store her spirometer when not in use. RN 1 further stated Resident 213 did not have one. On May 14, 2025, at 3:12 p.m., an interview with the IP was conducted. The IP stated the incentive spirometer should have been kept in a plastic bag container between exercises and should have label on it. The IP further stated if the incentive spirometer was not kept in proper storage, Resident 213 could have a respiratory infection. On May 15, 2025, Resident 213's record was reviewed. Resident 213 was admitted to the facility on [DATE], with diagnoses that included pulmonary edema (swelling of the lungs) and chronic obstructive pulmonary disease (lung disease). A review of Resident 213's History and Physical, dated May 6, 2025, indicated Resident 213 was mentally capable of understanding. A review of Resident 213's Order Summary, dated May 12, 2025, indicated, .INCENTIVE SPIROMETER. INSTRUCT PATIENT TO HOLD THEIR BREATH FOR 3 TO 15 BREATHS WITH YOUR SPIROMETER EVERY 4 HOURS .related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE . On May 15, 2025, at 9:16 a.m., an interview with the DON was conducted. The DON stated she expected the staff to follow the facility's infection control policy in the storage of medical devices. The DON stated the incentive spirometer should be kept in a bag with label. The DON further stated if not properly stored in a bag it could lead to respiratory infection. A review of the facility's policy and procedure titled, Incentive Spirometry, dated January 2025, indicated, .It is the policy of this facility that an incentive spirometry device may be used by a resident to assist with maximal lung ventilation .Place the mouthpiece in a plastic storage bag between exercises and label it and the spirometer with the resident's name . 3. On May 14, 2025, at 10:20 a.m., during a concurrent observation and interview with the Physical Therapist (PT) , the PT was observed not wearing PPE when providing therapy to Resident 216 in the rehabilitation room. The PT stated she provided physical therapy such as upper body exercises and stretching to Resident 216 and did not wear PPE. The PT further stated she should have worn PPE to prevent the spread of infection, protect herself and the facility residents from infection. On May 15, 2025, Resident 216's record was reviewed. Resident 216 was admitted to the facility on [DATE], with diagnoses which included muscle weakness and gastrostomy status (surgical opening in the stomach). A review of Resident 216's History and Physical, dated May 12, 2025, indicated Resident 216 was not mentally capable of understanding. A review of Resident 216's Order Summary, dated May 9, 2025, indicated, .ENHANCED BARRIER PRECAUTIONS: PPE required for high contact care activities. Indication: PEG-TUBE (tube inserted into stomach) . A review of Resident 216's Care Plan Report, dated May 12, 2025, indicated, .Has potential/actual impairment to skin integrity r/t (related to) PEG tube site Risk for infection, worsening impairment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555365 If continuation sheet Page 18 of 20 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 05/16/2025 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 0880 .Enhanced barrier precautions as ordered . Level of Harm - Minimal harm or potential for actual harm On May 14, 2025, at 11:10 a.m., an interview with the IP was conducted. The IP stated Resident 216 had a PEG tube and was on Enhanced Barrier Precaution. The IP further stated PT should have worn PPE before providing therapy to Resident 216 to prevent the spread of infection to the residents. Residents Affected - Some On May 15, 2025, at 9:20 a.m., during an interview with the DON, the DON stated the expectation was for the staff to follow the facility infection control policy and procedure. The DON further stated the PT should have worn PPE to prevent the spread of infection to Resident 216. A review of the facility's policy and procedure titled, Infection Control, dated January 2025, indicated, .It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions .Standard Precautions are infection prevention practices that apply to the care of all residents .Enhanced Barrier Protection (EBP): used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities .PPE: the use of gown and gloves for high-contact resident care activities is indicated when .Indwelling medical devices include .feeding tubes . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555365 If continuation sheet Page 19 of 20 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 05/16/2025 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation practices were maintained in the kitchen according to standards of practice and facility policy, for 67 out of 68 residents who consume food from the kitchen, when pests (a roach, a spider, and ants) were observed in the dry food storage pantry. In addition spiderwebs were also observed inside the kitchen. Residents Affected - Many These failures had the potential to expose residents to contaminated food, that could result in food borne illnesses for all residents who consume food from the kitchen. Findings: On May 12, 2025, at 07:01 a.m., a concurrent observation and interview was conducted in the facility's kitchen dry food storage room with the Dietary Supervisor (DS). The floor had a roach (bug), spiders, and ants on the floor. There was spiderwebbing on the metal carts. The DS stated pests should not be in the dry food storage room. On May 14, 2025, at 12:45 p.m., a follow up interview with the DS was conducted. The DS stated the expectation was for the facility to not have any pests. The DS also stated pests could multiply to more pests and pest droppings or fecal matter could contaminate the food. The DS further stated the residents could get sick that if residents ate the contaminated food. On May 15, 2025, at 3:38 p.m., during an interview with the Registered Dietician (RD 1), RD 1 stated her expectation was to not see pests. RD 1 stated the kitchen should not have pest. RD 1 also stated she expected the staff to alert the supervisor of pest sightings. RD 1 stated pests should not be near the food to prevent contamination. RD 1 further stated the food could get contaminated and the residents could get sick. According to the 2022 Federal Food Code, section 3-307.00 Miscellaneous Sources of Contamination, indicated, .Food shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 to 3-306. A review of the facility's policy and procedures titled, Food and Nutrition Services: Food, Dry Storage of, dated January 2025, indicated, .It is the policy of this facility that all non-perishable foods shall be stored utilizing methods which maximize nutrient retention .The storeroom shall be maintained free from .insects, rodents, or any potential source of contamination . A review of the facility's policy and procedures titled, Dietary Services: Dietary, Sanitation in, dated January 2025, indicated, .It is the policy of this facility that the food service area shall be maintained in a clean and sanitary manner .All kitchens, kitchen areas, and dining areas shall be kept clean .and protected from rodents, roaches, flies and other insects . A review of the facility's policy and procedures titled, Infection Control: Pest Control dated January 2025, indicated, .It is the policy of this facility to provide an environment free of pest . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555365 If continuation sheet Page 20 of 20