Health inspection·March 14, 2024

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. 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 implement their policy on abuse prevention when Licensed Vocational Nurse (LVN) 1 did not identify, recognize, and believe a resident's allegation that a staff member came to her room and slapped her buttock while changing her diaper, for one resident reviewed (Resident 16). In addition, LVN 1 did not identify Resident 16's allegation as abuse due to the resident's history of reporting false allegations. Residents Affected - Few This failure had the potential for Resident 16 and other residents to not be protected from potential abuse and the allegation not being investigated timely. Findings: On March 13, 2024, at 10:30 a.m., during a confidential Resident Council meeting held during the facility's re-certification survey, Resident 16 stated a little girl came to her room on noc shift (night) and slapped her buttock while changing her diaper. During an interview on March 13, 2024, at 11:46 a.m., with LVN 2 she stated she was not aware of Resident 16's allegation. She stated she did not receive any report from the staff or from Resident 16 herself regarding her allegation. During an interview on March 13, 2024, at 11:56 a.m., with LVN 3 who was the charge nurse at the beginning of the day shift, she stated she was not aware of Resident 16's allegation. She stated she did not get any report from the noc shift charge nurse about Resident 16's allegation. During an interview on March 13, 2024, at 12:07 p.m., with the Social Service Director (SSD), the SSD stated she was not aware of Resident 16's allegation. The SSD stated she spoke with Resident 16 after the meeting and was told by Resident 16 that the incident happened two months ago. During a concurrent observation and interview on March 13, 2024, at 2:25 p.m., with Resident 16 in her room, Resident 16 was observed sitting at the edge of her bed. Resident 16 stated the incident happened a week ago and it happened in her room. She stated she called for a staff to change her diaper. She stated Certified Nursing Assistant (CNA) 2 came to her room. She described her as little girl with curly hair and black. She stated when she got out of the bathroom the CNA started putting a new diaper and slapped her butt several times. She stated I think she was just playing. Resident 16 stated she did not want the CNA to do it again. Resident 16 stated she told the charge nurse, LVN 1, last night on March 12, 2024. During a review of the facility's document titled, NURSING STAFFING ASSIGNMENT AND SIGN-IN SHEET, from March 6, 2024 to March 12, 2024, with shift time of 10 p.m. to 6:30 a.m., the assignment sheet indicated CNA 2 was assigned to care for Resident 16 on March 6, 2024. On March 13, 2024, a record review was conducted for Resident 16. Resident 16 was admitted to the facility on [DATE], with diagnoses which included pneumonia (lung infection) bipolar disorder (a disorder that includes high energy, reduced need for sleep and loss of touch with reality). The history and physical dated January 13, 2024, indicated Resident 16 can make needs known but can (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555711 If continuation sheet Page 2 of 22 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 555711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care on Palm 4768 Palm Avenue Riverside, CA 92501 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 0607 not make medical decisions. Level of Harm - Minimal harm or potential for actual harm The Minimum Data Set (an assessment tool) dated February 1, 2024, indicated Resident 16 had a Brief Interview for Mental Status (BIMS - a screening tool to assess mental capacity) score of 12, suggestive of moderate cognitive impairment. Residents Affected - Few On March 14, 2024, at 10:22 a.m., Resident 16 was observed awake in her room. Resident 16 stated she just woke up since she did not sleep well last night. Resident 16 stated she could not recall the exact date when the CNA smacked her butt. She stated it did not hurt. On March 14, 2024, at 10:30 a.m., an interview was conducted with LVN 1. LVN 1 stated on March 12, 2024, on noc shift, Resident 16 told her the CNA smacked her butt three times and grabbed her breast. She stated she asked Resident 16 when it happened. Resident 16 told her it happened Sunday (March 10, 2024) or a week ago. LVN 1 stated Resident 16 had made several false accusations before, and she did not think it was true. LVN 1 stated she did not identify or consider Resident 16's allegations as abuse. She stated she identified the allegation as another behavior of Resident 16's making false accusations towards staff. LVN 1 stated she did not report Resident 16's allegation to the Administrator. LVN 1 stated on March 12, 2024, she sent a text message to the Director of Staff Development/Infection Preventionist (DSD/IP) regarding Resident 16 making false accusations. LVN 1 stated she should have contacted the Administrator. During a concurrent interview and text message review on March 14, 2024, at 11 a.m., with the DSD/IP, the text message in the DSD/IP's phone indicated, Tuesday 6:47 AM (name of Resident 16) is making false accusations about staff and molestation. She did not sleep much last night . The DSD/IP stated, that was my mistake. She stated she did not report LVN 1's text message to the Administrator or report Resident 16's allegation immediately on March 12, 2024. On March 14, 2024, at 11:20 p.m., an interview was conducted with the Administrator (ADM). The ADM stated he was not aware of Resident 16's allegation prior to the Resident Council meeting. The ADM stated licensed staff on noc shift on March 12, 2024, should have reported Resident 16's allegation immediately to him and to the California Department of Public Health (CDPH). On March 14, 2024, at 12:28 p.m., an interview was conducted with CNA 2. CNA 2 stated she had not taken care of Resident 16 for a while. CNA 2 stated she was not aware of Resident 16's allegation. CNA 2 stated no one had spoken to her about Resident 16's allegation. The facility's document titled, Behavior Occurrence, dated March 12, 2024, at 3:12 a.m., was reviewed. The document indicated, .Resident is making false accusations towards staff in regards to her ADL (Activity of Daily Living) care. Resident is stating she was molested/physically abuse because her diaper and shirt was changed. Resident stated staff member spanked her behind, and touched her breast 3-4 days ago which staff member in question was not present 3-4 days ago. Please render care to resident with assistance and not alone . The Behavior Occurrence report was documented by LVN 1, in Resident 16's record. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555711 If continuation sheet Page 3 of 22 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 555711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care on Palm 4768 Palm Avenue Riverside, CA 92501 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During a review of the facility's policy and procedure titled, Abuse Prevention Program, dated December 2016, indicated, .Our residents have the right to be free from abuse .includes but not limited to .physical abuse .As part of the resident abuse prevention, the administration will .Protect our residents from abuse by .facility staff .Develop and implement policies and procedures to aid our facility in preventing abuse .Require staff training/orientation programs include .abuse prevention, identification and reporting of abuse .Identify and assess all possible incidents of abuse . Event ID: Facility ID: 555711 If continuation sheet Page 4 of 22 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 555711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care on Palm 4768 Palm Avenue Riverside, CA 92501 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident's allegation of abuse was immediately reported to the Administrator or State Agency at the mandated time frame (immediately but not later than two hours), when a resident told Licensed Vocational Nurse (LVN) 1, a Certified Nursing Assistant (CNA) slapped her buttock while changing her diaper, for one of one resident reviewed (Resident 16). This failure had the potential to place Resident 16 and other residents' at risk from harm and delayed the investigation of an allegation of abuse. Findings: On March 13, 2024, at 10:30 a.m., during a confidential Resident Council meeting held during the facility's re-certification survey, Resident 16 stated a little girl came to her room on noc shift (night) and slapped her buttock while changing her diaper. During an interview on March 13, 2024, at 11:46 a.m., with LVN 2 she stated she was not aware of Resident 16's allegation. She stated she did not receive any report from the staff or from Resident 16 herself regarding her allegation. During an interview on March 13, 2024, at 11:56 a.m., with LVN 3 who was the charge nurse at the beginning of the day shift, stated she was not aware of Resident 16's allegation. She stated she did not get any report from the noc shift charge nurse about Resident 16's allegation. During an interview on March 13, 2024, at 12:07 p.m., with the Social Service Director (SSD), the SSD stated she was not aware of Resident 16's allegation. The SSD stated she spoke with Resident 16 after the meeting and was told by Resident 16 that the incident happened two months ago. During a concurrent observation and interview on March 13, 2024, at 2:25 p.m., with Resident 16, in her room, Resident 16 was observed sitting at the edge of her bed. Resident 16 stated the incident happened a week ago in her room. She stated she called for staff to change her diaper. She stated a CNA came to her room. She described her as little girl with curly hair and black. She stated when she got out of the bathroom the CNA started putting a new diaper and slapped her butt several times. She stated, I think she was just playing and said she did not want the CNA to do it again. Resident 16 stated she told the charge nurse, LVN 1, last night on March 12, 2024. On March 13, 2024, a record review was conducted for Resident 16. Resident 16 was admitted to the facility on [DATE], with diagnoses which included pneumonia (lung infection) bipolar disorder (a disorder that includes high energy, reduced need for sleep and loss of touch with reality). The history and physical dated January 13, 2024, indicated Resident 16 can make needs known but can not make medical decisions. The Minimum Data Set (an assessment tool) dated February 1, 2024, indicated Resident 16 had a Brief Interview for Mental Status (BIMS - a screening tool to assess mental capacity) score of 12, suggestive of moderate cognitive impairment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555711 If continuation sheet Page 5 of 22 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 555711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care on Palm 4768 Palm Avenue Riverside, CA 92501 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On March 14, 2024, at 10:22 a.m., Resident 16 was observed awake in her room. Resident 16 stated she just woke up since she did not sleep well last night. Resident 16 stated she could not recall the exact date when the CNA smacked her butt. She stated it did not hurt. On March 14, 2024, at 10:30 a.m., an interview was conducted with LVN 1. LVN 1 stated on March 12, 2024, on noc shift, Resident 16 told her the CNA smacked her butt three times and grabbed her breast. She stated she asked Resident 16 when it happened. Resident 16 told her it happened Sunday (March 10, 2024) or a week ago. LVN 1 stated Resident 16 had made several false accusations before, and she did not think it was true. LVN 1 stated she did not identify or consider Resident 16's allegations as abuse. She stated she identified the allegation as another Resident 16's behavior of making false accusations towards staff. LVN 1 stated she did not report Resident 16's allegation to the Administrator. LVN 1 stated on March 12, 2024, she sent a text message to the Director of Staff Development/Infection Preventionist (DSD/IP) regarding Resident 16 making false accusations. LVN 1 stated she should have contacted the Administrator. During a concurrent interview and text message review on March 14, 2024, at 11 a.m., with the DSD/IP, the text message in DSD/IP's phone indicated, .Tuesday 6:47 AM (name of Resident 16) is making false accusations about staff and molestation. She did not sleep much last night . The DSD/IP stated, that was my mistake. She stated she did not report LVN 1's text message to the Administrator or reported Resident's 16's allegation immediately on March 12, 2024. On March 14, 2024, at 11:20 p.m., an interview was conducted with the Administrator (ADM). The ADM stated he was not aware of Resident 16's allegation prior to the Resident Council meeting. The ADM stated licensed staff on noc shift on March 12, 2024, should have reported Resident 16's allegation immediately to him and to the California Department of Public Health (CDPH). During a review of the facility's policy and procedure titled, Abuse Investigation and Reporting, dated July 2017, indicated, .All alleged violations involving abuse .mistreatment .will be reported by the Administrator, or his/her designee, to the State licensing/certification agency responsible for surveying/licensing the facility .All alleged violation of abuse .will be reported immediately, but not later than .two hours (2) hours if the alleged violation involves abuse . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555711 If continuation sheet Page 6 of 22 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 555711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care on Palm 4768 Palm Avenue Riverside, CA 92501 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to initiate a care plan for resident's left lower chin swelling and redness on March 8, 2024, for one of one resident reviewed (Resident 5). This failure had the potential to delay the necessary care and services for Resident 5's left lower chin redness and swelling. Findings: On March 11, 2024, at 11:48 a.m., Resident 5 was observed sitting in a Geri chair (geriatric chair - used for patient with difficulty sitting upright) in the dining room. Resident 5 was alert and able to verbalize his needs. Resident 5's teeth was observed with blackish discoloration with irregular shapes and some teeth were missing. He stated he could chew on his food. His left lower chin area was observed with some swelling and some redness. Resident 5 was asked if he was seen by the dentist. He stated he did not want to see a dentist, he just wanted to take an antibiotic. The Activity Coordinator (AC) was present in the dining area. The AC stated she noticed Resident 5's left lower chin with some swelling a few days ago and reported to the charge nurse. During a concurrent observation and interview on March 11, 2024, at 11:55 a.m., with Licensed Vocational Nurse (LVN) 3 in the facility's dining room, Resident 5 was observed sitting in his Geri chair. LVN 3 acknowledged Resident 5's left lower chin had some redness and swelling. LVN 3 stated Resident 5 had a physician order for warm compress three days ago. On March 13, 2024, at 10:09 a.m., Resident 5 was observed lying in bed. Resident 5 stated he received an antibiotic for his left lower bump yesterday. Resident 5 denied any pain. His left lower chin area was observed with some redness and with some swelling. On March 13, 2024, Resident 5's record was reviewed. Resident 5 was admitted to the facility on [DATE], with diagnoses which included chronic respiratory failure, dementia (memory loss), and depressive disorder. The Minimum Data Set ( MDS - an assessment tool) dated February 20, 2024, indicated a Brief Interview for Mental Status (BIMS) score of nine, indicating moderate cognitive impairment. The physician's history and physical dated March 10, 2024, indicated Resident 5 had fluctuating capacity to understand and make decisions. The physician's order dated March 8, 2024, indicated, .Warm compress to left side of the chin three times a day for TX (treatment) for 14 days . The facility's document titled, 72 hours monitoring indicated Resident 5 had a bump with redness to the left side of the chin. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555711 If continuation sheet Page 7 of 22 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 555711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care on Palm 4768 Palm Avenue Riverside, CA 92501 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On March 13, 2024, at 11:30 a.m. a concurrent record review and interview was conducted with the LVN 2. LVN 2 stated on March 8, 2024, she was notified by the Certified Nursing Assistant (CNA) staff that Resident 5 had some redness on his left lower chin area. LVN 2 stated she assessed Resident 5 and noted the bump and redness on his left lower chin. LVN 2 acknowledged she received the physician's order to apply warm compress to Resident 5's left chin three times a day. LVN 2 stated she did not initiate a care plan for Resident 5's left lower chin bump and redness. She stated she should have initiated a care plan on March 8, 2024. On March 13, 2024, at 12:18 p.m., a concurrent interview and record review was conducted with the Interim Director Of Nursing (IDON). There was no documented evidence a care plan was initiated on March 8, 2024, for Resident 5's left lower chin redness and swelling. The IDON stated LVN 2 should have initiated a care plan for Resident 5's left lower chin's swelling and redness on March 8, 2024. The facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, dated December 2016, was reviewed. The policy indicated, .A comprehensive , person-centered care plan that includes measurable objectives and time tables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555711 If continuation sheet Page 8 of 22 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 555711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care on Palm 4768 Palm Avenue Riverside, CA 92501 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 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the facility staff have a current and active Cardio-Pulmonary Resuscitation (CPR - a life-saving procedure used to restart a person's heartbeat and breathing after one or both have stopped) certification, when two of 11 Certified Nursing Assistants (CNA) had expired CPR certification. This failure had the potential for the facility residents not to receive emergency care leading to resident harm and/or death. Findings: During a review of CNA 2's employee file, CNA 2 was hired by the facility on [DATE]. The copy of CNA 2's CPR certification indicated an expiration date of [DATE]. There was no documented evidence CNA 2 had a current CPR certification. During a review of CNA 1's employee file, CNA 1 was hired by the facility on February 22, 2023. A copy of CNA 1's CPR certification was not found in the employee file. During a concurrent interview and record review on [DATE], at 3:10 p.m., with the Director for Staff Development/Infection Preventionist (DSD/IP), she stated CNA 2's CPR certification had an expiration date of [DATE]. There was no documented evidence CNA 2 had a current CPR certification. During a concurrent interview and record review on [DATE], at 3:10 p.m., with the DSD/IP, the DSD/IP stated there was no current CPR certification on file for CNA 1. The DSD/IP stated a CPR certification was not a requirement on the facility's new hire check list. A review of the facility's undated document Certified Nuring Assistant, job description, indicated CPR certification was required for CNA staff. The DSD/IP stated if the facility required a CPR certification for CNA staff, the CPR certification should have been obtained and filed in all employee records. The DSD/IP agreed CNA 1's CPR certification was not available in CNA 1's employee file. During a review of the facility's undated document, titled, Certified Nurses Assistant, the document indicated, .POSITION SUMMARY .The purpose fo your job description is to perform direct patient care activities in a skilled nursing facility environment and ensure the health and comfort of the patients .REQUIREMENTS .BLS and CPR certification . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555711 If continuation sheet Page 9 of 22 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 555711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care on Palm 4768 Palm Avenue Riverside, CA 92501 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 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 for two of two residents reviewed (Residents 22 and 42), to ensure: Residents Affected - Few 1. For Resident 22, the licensed staff assessed, notified the physician, and documented when Resident 22 experienced low blood sugar (BS). This failure had the potential for a delay in treatment that could lead to harm and/or death for Resident 22. 2. For Resident 42, followed the regular diet order when Resident 42 received pureed (food blended to a smooth, creamy consistency) bread during lunch on March 13, 2024. This failure resulted in Resident 42's feeling of dissatisfaction with her meals. Findings 1. During an observation on March 13, 2024, at 11:29 a.m., Resident 22 wheeled herself to the nurse's station. Resident 22 asked for her nurse to check her BS. During an interview on March 13, 2024, at 11:35 a.m., with Resident 22, Resident 22 stated the nurses checked her BS three times a day before meals. Resident 22 stated she felt her sugar was low usually around 4 a.m. Resident 22 stated this happened at least every 10 days and the nurses knew about it. Resident 22 stated sometimes she did not take her 42 units of insulin (medication to lower blood sugar) because it was a lot. During a concurrent interview and record review on March 13, 2024, at 3:15 p.m., with Licensed Vocational Nurse (LVN) 4, LVN 4 stated Resident 22's blood sugar was checked three times a day before meals. LVN 4 stated Resident 22 had an order for Lantus (long acting insulin - a type that takes the longest amount of time to start working) 42 units subcutaneously (injection of medication beneath the skin) at bedtime and Humalog (short acting insulin - a type of insulin that takes about 30 to 60 minutes to start working) as per sliding scale (progressive increase in dose, based on blood sugar ranges) before meals. During a telephone interview on March 14, 2024, at 8:57 a.m., with LVN 1, LVN 1 stated Resident 22's blood sugar would drop between 3 a.m. and 6 a.m. LVN 1 stated Resident 22 was symptomatic (showing signs or symptoms) when her BS was low. LVN 1 stated Resident 22's skin was cold and clammy (damp) and Resident 22 told her if she did not feel good. LVN 1 stated she checked Resident 22's BS to verify if it was low, gave her snacks and juice and rechecked the BS. LVN 1 stated she called and notified the physician when Resident 22's BS was low and was not sure if she informed the next shift for follow-up. LVN 1 stated she was not able to document Resident 22's change of condition and physician notification because she did not have time. During a concurrent interview and record review on March 14, 2024, at 9:34 a.m., with the Interim Director of Nursing (IDON) the IDON stated the nurses should have assessed, notified the physician, and documented when Resident 22's BS was low. The IDON stated there was no documented evidence the nurses assessed, notified the physician, and documented when Resident 22's BS was low. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555711 If continuation sheet Page 10 of 22 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 555711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care on Palm 4768 Palm Avenue Riverside, CA 92501 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 Residents Affected - Few During an interview on March 14, 2024, at 9:52 a.m., with LVN 3, LVN 3 stated she was made aware of Resident 22's low BS by the night shift licensed staff. LVN 3 stated when a resident's BS was low, the nurse should assess the resident, give juice or snacks to stabilize the BS, notify the physician and document. During a review of Resident 22's admission Record (AR), the AR indicated Resident 22 was admitted to the facility on [DATE], with diagnoses which included diabetes (too much sugar in the blood). During a review of Resident 22's Physician's Order, dated December 3, 2023, the order indicated, .Lantus Subcutaneous Solution 100 UNIT/ML (a unit of measurement) Inject 42 units subcutaneously at bedtime for DM (diabetes mellitus) . During a review of Resident 22's Physician Order, dated March 7, 2023, the order indicated, .Humalog inject per sliding scale; 201-250 = 2u (units); 251-300 = 4u; 301-350 = 6u; 351-350 = 8u; if BS 400 or above call MD (medical doctor/physician), subcutaneously before meals and at bedtime for DM. There was no parameter or instructions noted for BS below 200 mg/dL (a unit of measurement) and Resident 22 was symptomatic. During a review of Resident 22's Medication Administration Record (MAR), from January 1, 2024 to March 14, 2024, the following were indicated: - January 5, 2024, at 5:44 a.m., Blood Sugar (BS) of 82 mg/dL; - January 10, 2024, at 5:52 a.m., BS of 79 mg/dL; - January 11, 2024, at 5:46 a.m., BS of 77 mg/dL; - January 24, 2024, at 5:49 a.m., BS of 84 mg/dL; - January 31, 2024, at 5:54 a.m., BS of 69 mg/dL; - February 13, 2024, at 5:44 a.m., BS of 85 mg/dL; - February 20, 2024, at 5:43 a.m., BS of 76 mg/dL; - February 21, 2024, at 6:05 a.m., BS of 51 mg/dL: - February 23, 2024, at 6:11 a.m., BS of 85 mg/dL; and - February 29, 2024, at 5:46 a.m., BS of83 mg/dL. During a review of Resident 22's Care Plan (CP), initiated March 7, 2023, the CP indicated, .Focus .Diabetes Mellitus .Goal .No acute hypo-/hyperglycemia (low/high blood sugar) through the review date .Interventions/Tasks .Observe for and report s/sx (signs/symptoms) of hypoglycemia, including sweating, tremor, increased heart rate (tachycardia), pallor, nervousness, confusion, slurred speech, lack of coordination, staggered gait . During a review of the facility's policy and procedure (P&P), titled Change in a Resident's Condition or Status, revised February 2021, the P&P indicated, .Our facility promptly notifies the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555711 If continuation sheet Page 11 of 22 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 555711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care on Palm 4768 Palm Avenue Riverside, CA 92501 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 Residents Affected - Few resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status .The nurse will notify the resident's attending physician or physician on call when there has been a (an) .significant change in the resident's physical/emotional/mental condition .Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather pertinent information for the provider, including (for example) information prompted by the Interact SBAR (Situation, Background, Assessment and Recommendation) Communication Form .The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . 2. During a concurrent observation and interview on March 11, 2024, at 3:27 p.m., Resident 42 was in her room, sitting in bed. Resident 42 stated all her food was chopped and she was given pureed pancakes. Resident 42 stated she could eat regular food except for the meat that should be chopped. Resident 42 pointed at a sign posted on her wall. The posted sign had instructions, dated February 23, 2024, for swallowing guidelines as follows: .DIET CONSISTENCY .REGULAR .NO PORK, NUTS, RAW VEGGIES, SALAD .SUPERVISION .POPCORN .OK TO EAT .POPCORN (WITH SUPERVISION), BURRITOS, SANDWICHES, CHIPS, PRETZELS, FRITOS . During a concurrent observation and interview on March 13, 2024, at 9:52 a.m., Resident 42 was ambulating in the hallway. Resident 42 stated her food was still chopped and she did not like it. During an interview on March 13, 2024, at 11:39 a.m., with Certified Nursing Assistant (CNA)3, CNA 3 stated Resident 42 was complaining about her food being chopped and asked why she could not have the regular diet. CNA 3 stated the licensed nurses were aware Resident 42 did not like chopped food especially the sandwich. During an interview on March 13, 2024, at 11:49 a.m., with the Restorative Nursing Assistant (RNA), the RNA stated Resident 42 had an English muffin cut up into four pieces. The RNA stated Resident 42 was not happy about her cut up food. During an observation on March 13, 2024, at 12:03 p.m., in the dining area, Resident 42 was eating lunch. Resident 42 was served ravioli with pureed bread. Resident 42 did not talk and was picking at her food. During an interview on March 13, 2024, at 2:45 pm., with the Dietary Service Supervisor (DSS), the DSS stated Resident 42's diet order was regular with regular texture, regular consistency. The DM stated the diet order for Resident 42 also indicated to chop chicken. The DM stated Resident 42 should have not been served pureed bread with lunch on March 13, 2024. During a review of Resident 42's admission Record (AR), the AR indicated Resident 42 was admitted to the facility on [DATE], with diagnoses which included gastro-esophageal reflux disease (GERD - a condition in which the stomach contents move up into the esophagus - an organ that food travels through to reach the stomach), and depression (feelings of sadness or feeling low). During a review of Resident 42's SLP (Speech Language Pathology) Evaluation & Plan of Treatment (SLPE & POT), dated February 23, 2024, indicated, .RECOMMENDATIONS .Commence regular solids .thin liquids .NO; Really hard solids .NO PORK per pt (patient) preference .Pt may consume chips/fritos/Cheetos, pretzels, popcorn (w/ supervision), cold cereal, and meat sandwiches . During a review of Resident 42's Physician's Order (PO), dated February 23, 2024, the order (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555711 If continuation sheet Page 12 of 22 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 555711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care on Palm 4768 Palm Avenue Riverside, CA 92501 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 Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete indicated, .Regular diet, Regular texture, Regular consistency. Pls. chop chix (chicken) & given tender veggies. NO: Raw veggies, salad, nuts, pork. OK TO EAT: Burritos, WHOLE Sandwiches, Pretzels, chips, Fritos, Popcorn (w/ supervision) . During a review of the facility's policy and procedure (P&P) titled, Therapeutic Diets, revised October 2017, the P&P indicated, .Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences . Event ID: Facility ID: 555711 If continuation sheet Page 13 of 22 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 555711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care on Palm 4768 Palm Avenue Riverside, CA 92501 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 provide respiratory care and treatment for one of two residents reviewed for oxygen administration (Resident 10), when the physician's order for oxygen administration was not followed. Residents Affected - Few This failure had the potential to result in ineffective oxygen therapy, respiratory distress, and decline in the resident's health condition. Findings: On March 11, 2024, at 11:04 a.m., Resident 10 was observed in bed with oxygen (O2) via nasal cannula (NC - a tube used to deliver oxygen through the nose). Resident 10's oxygen administration was observed at 3 liters per minute (LPM). On March 11, 2024, at 11:23 a.m., a concurrent observation, interview and record review was conducted with Licensed Vocational Nurse (LVN) 2. LVN 2 confirmed the O2 level for Resident 10 was at 3 LPM. LVN 2 verified the physician order and stated the O2 level should be at 2 LPM, as per physician's order. LVN 2 stated the physician's order was not followed. On March 13, 2024, at 11:18 a.m., a concurrent interview and record review was conducted with the Interim Director of Nursing (IDON). The IDON confirmed the O2 level should be at 2 LPM, as per physician's order. The IDON stated the physician's order was not followed. Resident 10's record was reviewed. Resident 10 was admitted to the facility on [DATE], with diagnoses which included heart failure (a condition when the heart does not pump enough blood), asthma (a chronic lung disease) and obstructive sleep apnea (interrupted breathing during sleep). The physician's order dated November 10, 2023, indicated, .Oxygen at 2 L/min (LPM) via nasal cannula . The facility policy and procedure titled, Oxygen Administration, revised October 2010, was reviewed. The policy indicated, .The purpose of this procedure is to provide guidelines for safe oxygen administration .Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555711 If continuation sheet Page 14 of 22 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 555711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care on Palm 4768 Palm Avenue Riverside, CA 92501 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to ensure the lunch menu was followed on February 27, 2024, when residents were served two and a half ounces of chicken instead of three ounces as indicated on the menu for lunch on Monday, March 11, 2024. This failure had the potential for residents' nutritional needs not to be met by being served less than the menu stated portion in accordance with a prescribed regular diet. Findings: During an observation on March 11, 2024, at 11:54 a.m., of the facilities lunch preparation, the cook served a piece of chicken on each of the residents' plate who was on a regular diet. She used tongs to pick up the piece of chicken and place it on the residents' plates. The chicken portion being served was weighed by the Dietary Services Supervisor (DSS) and it was two and a half ounces. A review of the lunch menu for Monday, March 11, 2024, indicated Herb and Honey Glazed Chicken .3 oz. (ounces - unit of measurement). During an interview with the facility's Registered Dietitian (RD) on March 12, 2024, at 2:36 p.m., RD stated the chicken portion size should be three ounces if that is what it says on the menu. A review of the facility policy and procedure (P&P) titled Menus, dated October 2017 indicated .Menus meet the nutritional needs of residents in accordance with the recommended dietary allowances . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555711 If continuation sheet Page 15 of 22 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 555711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care on Palm 4768 Palm Avenue Riverside, CA 92501 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview, and record review the facility failed to ensure pureed (food blended to a smooth, creamy consistency) food was the appropriate consistency to meet the individual needs of four out of 44 residents (Residents 4, 5, 10 and 25). This failure had the potential for residents on a pureed diet to aspirate (draw food into the lungs) and/or negatively impact the resident's dining experience resulting in poor food intake, compromising their nutritional status. Findings: During tray line observation on March 11, 2024, at 11:53 a.m., the pureed chicken was a chunky consistency and not smooth. During a test tray evaluation on March 12, 2024, at 12:19 p.m., the pureed ground beef had a texture of crumbles, (not smooth) and required chewing to swallow. An interview with the Dietary Services Supervisor (DSS) was conducted on March 12, 2024, at 12:25 p.m. The DSS stated the pureed beef was not smooth and It needs to be more moist and should have more broth. The DSS further stated the beef was too crumbly. During an interview with the facilities Registered Dietician (RD) on March 12, 2024, at 2:40 p.m., the RD stated the expectation is that pureed food has to be soft and completely pureed, no chunks and very moist and very soft. The RD further stated the risk of food not being properly pureed was if a resident has dysphagia (difficulty swallowing), it could cause discomfort and aspiration is a risk. During a review of facility document titled Diet Type Report, dated March 11, 2024, the document indicated, four residents were on a pureed diet order. A review of the facility document titled Diet Manual, Dietary Directions, dated 2018, indicated .The puree diet provides foods that do not require chewing and are easily swallowed .All foods should be smooth and pureed to the consistency of pudding . A review of the facility document titled Recipe Name: Pureed Fish/Meat Poultry dated August 20, 2018, indicated .Process until meat is smooth in consistency. Gradually add broth and thickener to meat while processing . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555711 If continuation sheet Page 16 of 22 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 555711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care on Palm 4768 Palm Avenue Riverside, CA 92501 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 safe and sanitary conditions were maintained in the kitchen for food storage methods and food sanitation equipment when the ice machine was observed to have a build-up of a slimy pink, yellow and bright green substances where ice is formed. This failure had the potential for contamination, which could result in food borne illnesses for all residents who consume ice from the facility's ice machine. The facility census was 44. Findings: On March 11, 2024, at 9:31 a.m., an observation and concurrent interview with the facility's Maintenance Supervisor (MS) was completed. The MS opened the interior of the ice machine, there was a slimy pink and yellow substances on the white shield that was over the ice grates. There was bright green build-up where the water flows out of the ice grates. The MS stated the ice machine was last cleaned on January 11, 2024, with a descaler (a solution used to remove a coating, layer, or crust from a surface). The MS stated he uses a descaler to clean the ice machine every six months. The MS further stated the manufacturer's instructions for cleaning were not clear and he had been trying to contact the manufacturer to get more detailed instructions on how to clean the machine but had not received a response. He stated he was using a descaler because it was what he used on the last ice machine they had. During an interview with the Dietary Services Supervisor (DSS) on March 11, 2024, at 9:46 a.m., the DSS stated she does not inspect the top part of the ice machine where the ice is made. The DSS stated it is the responsibility of building maintenance to remove the cover and clean inside of the machine. The DSS stated the expectation is that the ice machine is clean and has no build-up of any kind. During an interview with the Director of Staff Development/Infection Preventionist (DSD/IP) on March 11, 2024, at 9:41 a.m., she stated the ice machine should be kept clean and not have any discolorations. During a follow-up interview with MS on March 12, 2024, at 11:03 a.m., the MS stated the ice machine should be cleaned more often. During an interview with the facility's Registered Dietician (RD), she stated The ice machine should be absolutely clean. The RD also stated the slimy residue and build-up could be harmful for residents; it could cause a health hazard and will make residents sick with nausea, vomiting and diarrhea. The RD further stated she felt that the ice machine should be more frequently cleaned, every three months or as needed. It should be cleaned to prevent buildup. According to the 2022 Federal FDA Food Code, section 4-602.11 titled Equipment Food-Contact Surfaces and Utensils which states .In equipment such as ice makers .shall be cleaned .Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold .bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. If the manufacturer does not provide cleaning specifications for food-contact surfaces of equipment that are not readily visible, the person in charge should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555711 If continuation sheet Page 17 of 22 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 555711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care on Palm 4768 Palm Avenue Riverside, CA 92501 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 develop a cleaning regimen that is based on the soil that may accumulate in those particular items of equipment . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555711 If continuation sheet Page 18 of 22 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 555711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care on Palm 4768 Palm Avenue Riverside, CA 92501 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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on interview and record review, the facility failed to ensure the facility assessment was reviewed and updated annually and as needed. This failure resulted in an inaccurate evaluation of the facility's population and resources needed to provide the necessary care and services for the residents. During a concurrent interview and record review on March 14, 2024, at 11:02 a.m., with the Administrator (ADM), the ADM stated he was responsible for conducting the facility assessment. The ADM stated the facility assessment should have been reviewed and updated annually. The ADM stated the facility assessment was not reviewed or updated annually. The ADM stated he was not able to initiate the facility assessment. The ADM stated the last facility assessment was on April 18, 2021. During a review of the facility's policy and procedure (P&P), titled, Facility Assessment, revised October 2018, the P&P indicated, .A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations .Once a year, and as needed, a designated team conducts a facility-wide assessment to ensure that the resources are available to meet the specific needs of our residents . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555711 If continuation sheet Page 19 of 22 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 555711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care on Palm 4768 Palm Avenue Riverside, CA 92501 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 Based on interview and record review, the facility failed to initiate and implement their water management program to ensure safe measures in the building's water system. Residents Affected - Many This failure had the potential to increase the risk of the development of Legionella (a specific bacteria that can cause serious type of pneumonia - lung infection) called Legionnaires disease, and other water-borne pathogens in the building's water system which can affect the health and safety of the residents. Findings: On March 13, 2024, at 9:25 a.m., an interview and a review of facility's Legionella Water Management Program was conducted with the Director of Staff Development/Infection Preventionist (DSD/IP). The DSD/IP stated the facility had no current water management measures to prevent Legionella. The DSD/IP was not able to provide documented evidence of the facility's monitoring measures to prevent the growth of Legionella in the facility's building water system. The DSD/IP stated the facility's Legionella Water Management Program was not acted upon and initiated. On March 14, 2024, at 10:08 a.m., an interview was conducted with the Administrator (ADM). The ADM stated the facility had no current water testing measures or other control measures in place for Legionella detection in the facility's water system. On March 14, 2024, at 1:54 p.m., the Maintenance Supervisor was interviewed. The MS stated he was not aware of the facility's water management program for Legionella. He stated he had not initiated any type of measures in the facility's water system to identify where the Legionella or other water bacteria can grow and spread. A review of the facility's policy and procedure titled, Legionella Water Management Program, dated July 2017, indicated, .Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella .The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555711 If continuation sheet Page 20 of 22 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 555711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care on Palm 4768 Palm Avenue Riverside, CA 92501 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. 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 for one of 44 residents (Resident 37), the call light was working. Residents Affected - Few This failure had the potential to result in the delay in answering the call light which could affect the delivery of care for Resident 37. Findings: During a concurrent observation and interview on March 11, 2024, at 11:55 a.m., with Resident 37, Resident 37 was seen lying across the bed in a supine (face up) position. Resident 37 was observed calling out for assistance. Resident 37 stated he was not able to get up on his own. Resident 37 stated he was not using the call light because it was not working. Resident stated the call light had been broken since he was placed in his room. A staff member was called to assist Resident 37. During a concurrent observation and interview on March 11, 2024, at 11:57 a.m., with Certified Nurse Assistant (CNA) 4, CNA 4 assisted Resident 37 to get up and sit on the side of the bed. CNA 4 verified the call light for Resident 37 was not working. During an interview on March 11, 2024, at 1:35 p.m., with CNA 4, CNA 4 stated Resident 37 was alert but forgetful. CNA 4 stated Resident 37 needs assistance with some activities of daily living. CNA 4 stated Resident 37 would ambulate by himself and at times would need to use the wheelchair. CNA 4 stated she was not aware Resident 37's call light was not working. During an interview on March 13, 2024, at 2:57 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 37 was alert and knew his name, place, and situation. LVN 2 stated Resident 37 was forgetful. LVN 2 stated Resident 37 was able to ambulate but at times would use the wheelchair. LVN 2 stated she was not aware the call light for Resident 37 was not working on March 11, 2023. During an interview on March 13, 2024, at 3:16 p.m., with the Maintenance Supervisor (MS), the MS stated he was responsible for maintaining the equipment were in good functioning condition. The MS stated when there was a need for repairs, the staff would write in the maintenance log. The MS stated he checked on the maintenance log twice a day, when he comes in the morning and before he leaves. During a review of the facility's maintenance log, there was no documented evidence a report was made prior to March 11, 2024, that Resident 37's call light was not working. During a review of Resident 37's admission Record (AR), the AR indicated Resident 37 was admitted to the facility on [DATE], with diagnoses which included abnormalities of gait and mobility (abnormality in walking and movement). During a review of Resident 37's History and Physical (H&P), dated January 20, 2024, the H&P indicated, Resident 37 had fluctuating capacity to understand and make decisions. During a review of Resident 37's Brief Interview for Mental Status (BIMS - an assessment tool for mental capacity), dated January 26, 2024, the BIMS indicated a score of 8 (moderate cognitive impairment). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555711 If continuation sheet Page 21 of 22 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 555711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care on Palm 4768 Palm Avenue Riverside, CA 92501 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 0919 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled, Answering the Call Lights, revised March 2021, the P&P indicated, .The purpose of this procedure is to ensure timely responses to the resident's requests and needs .Be sure that the call light is plugged and functioning at all times . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555711 If continuation sheet Page 22 of 22