Health inspection·June 27, 2024

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect the resident ' s right to be free from physical abuse for one out of six residents reviewed (Resident 2), when another resident (Resident 1) hit Resident 2 on the head with a cane. This failure resulted in Resident 2 sustaining four lacerations (deep cut/tear in skin) on his head and bruising to his hands and shoulder. Resident 2 was transferred to the acute hospital, where he received 18 staples (surgical staples - used to close large wounds or deep cuts) to treat his head wounds. Findings: On June 4, 2024, at 9:10 a.m., an unannounced visit was made to the facility to investigate a facility-reported resident-to-resident altercation between Resident 1 and Resident 2 on June 1, 2024. On June 4, 2024, at 9:30 a.m., Resident 1 was interviewed. Resident 1 was alert and oriented. Resident 1 stated he did hit his former roommate (Resident 2) in the head with a cane because he thought Resident 2 messed with his radio. Resident 1 stated the cane was not his and he did not remember how he got the cane. On June 4, 2024, Resident 1's medical record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included encephalopathy (brain dysfunction), schizoaffective disorder, bipolar type (schizophrenia - hallucinations, delusions, mixed with extreme mood swings), Alzheimer ' s disease (memory loss and confusion), and impulse disorder (difficulty controlling emotions and behaviors). Resident 1 ' s BIMS (Brief Interview for Mental Status - an assessment tool) score was 10, indicating moderate cognitive (thinking) impairment. Resident 1's care plan, dated December 20, 2023, was reviewed. The care plan indicated, .Episodes of physical and verbal aggression: [episodes of agitation .breaking windows, property destruction, removing signs from walls, taking iPad chargers, etc .Goal .Will demonstrate effective coping skills . Resident 1's care plan, dated January 24, 2024, was reviewed. The care plan indicated, .Impulse control disorder m/b (manifested by) mood swings . Resident 1's psychiatry (physician who treats mental illness) note, dated May 16, 2024, was reviewed. The note indicated, .Psych consulted with resident (Resident 1) today. Pt (patient - Resident 1) continues to display behaviors that require medication to manage. Pt continues to display disruptive (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 555711 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 06/27/2024 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)