Health inspection·November 25, 2025

F 0657 hospital/rehabilitation stay; and at least quarterly . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555711 If continuation sheet Page 2 of 4 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 11/25/2025 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 ensure two of two residents reviewed for breathing treatment therapy (Residents 4 and 2), were monitored during and after nebulizer treatments (breathing treatments that turn liquid medicine into a mist).This failure placed the residents at risk for delayed treatment related to possible complications of the nebulizing treatment such as rapid heart rate, restlessness, chest pain and/or difficulty breathing.Findings:1.On November 25, 2025, at 8:30 a.m., and observation was conducted with Resident 4. Resident was in bed, alert, and non-verbal. A nebulizer mask (mask used to breathe in medicated mist) was observed connected over her nose and mouth. The medication chamber (small cup that holds the liquid medicine) was observed empty. There was no licensed nurse observed beside Resident 4.On November 25, 2025, at 8:45 a.m., an interview was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated she should have stayed in the room with Resident 4 during the breathing treatment per facility policy. On November 25, 2025, at 9:10 a.m., an observation with a concurrent interview was conducted with LVN 1. She stated she was the licensed nurse assigned to Resident 4 and she administered the breathing treatment (misted medication session) at 8:00 a.m. LVN 1 stated each breathing treatment last approximately 15-20 minutes. LVN 1 stated she had left the room because another resident had called for assistance. LVN 1 stated the correct procedure was to remain with the resident during the breathing treatment to observe for difficulty breathing (trouble catching their breath). LVN 1 stated the possible outcome of leaving the mask on the resident after the medication was gone was that the resident may become anxious, have trouble breathing, or refuse the next treatment. On November 25, 2025, at 9:10 a.m. LVN 1 was observed removing the nebulizing mask off Resident 4.On November 25, 2025, Resident 4's record was reviewed. Resident 4 was admitted to the facility on [DATE], with diagnosis including hypoxia (low oxygen level in the blood).The physician's order dated December 4, 2024, indicated to administer .Albuterol Inhalation Solution 0.5-2.5 (3) MG(milligram-unit of measurement)/3(ML) (millimeter-unit of measurement) (Ipratropium-Albuterol) 1 Vial (nebulizer medication treatment/misted medication) . To be given three times a day for shortness of breath. The electronic Medication Administration Record (eMAR) dated November 25, 2025, indicated LVN 1 administered the medication Albuterol to Resident 4 at 8 a.m.On November 25, 2025 at 9:30 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated the licensed nurse was expected to remain with the resident during breathing treatment and remove the nebulizer face mask when the treatment was completed. 2. On November 25, 2025, at 8:54 a.m., an observation was conducted with Resident 2. Resident 2 was observed in bed, alert and oriented. Resident 2 had a nebulizer face mask in place with no medication solution remaining in the medication chamber. Resident 2 was observed with no licensed nurse present at bedside. On November 25, 2025, at 9:10 a.m., an interview was conducted with LVN 2. LVN 2 stated the correct way to administer a nebulizer treatment (breathing-mist medication) is to observe the resident for any difficulty breathing (trouble catching their breath) and remain with the resident during medication administration. LVN 2 stated it was not acceptable to leave the mask on Resident 2 for an hour because there is no medication solution left. LVN 2 stated she gave the breathing treatment medication, left the resident, and did not turn off the machine until 9:10 a.m. LVN 2 stated the possible outcome of leaving the mask on for that length of time is the resident might become anxious and refuse the next breathing treatment. LVN 2 stated she left the room because she was called out to assist another resident. LVN 2 stated that Resident 2 had the face mask on for an hour. LVN 2 stated each breathing treatment (mist medication session) lasts approximately 15 minutes. On November 25, 2025, Resident 2's record was reviewed. Resident 2 was Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555711 If continuation sheet Page 3 of 4 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 11/25/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete admitted to the facility on [DATE], with diagnosis including Chronic Respiratory Failure with Hypoxia (low oxygen in the blood)A physician order dated April 4,2025, indicated to administer, .Budenoside Inhalation suspension (breathing treatment medication) 0.5 MG (milligrams- unit of measurement)/2ML (milliliters unit of measurement) 1 mg inhale two times a day related to for Chronic Obstructive Pulmonary Disease with Exacerbation (a long-term lung disease that makes it hard to breath, with a recent flare-up/worsening episode) . The electronic Medication Administration Record (eMAR) dated November 25, 2025 indicated LVN 2 administered the medication Budenoside at 8:00 a.m. On November 25,2025 at 9:30 a.m., an interview was conducted with the Director of Nursing (DON) The DON stated the licensed nurse should have removed Resident 2's nebulizer face mask once the medication was completed and monitored the resident during and after the treatment for any signs of difficulty breathing, anxiety, or distress. The DON stated this practice was required to ensure resident safety during breathing treatments.The facility's policy and procedure titled, Administering Medications Through a Small Volume Nebulizer, dated October 2010 was reviewed. The policy indicated, .The purpose of this procedure is to safely and aseptically (free from contamination) administer aerosolized particles of medication into the resident's airway . General guidelines are to follow the medication administration guidelines in the policy entitled Administering Medications .Steps in the Procedure .Assemble nebulizer equipment and attach to the source of gas per manufacture's instructions .Turn off the nebulizer and check the outflow port for visible mist .Instruct the resident to take a deep breath, pause briefly and then exhale normally .Encourage the resident to repeat the above breathing pattern until the medication is completely nebulized, or until the designated time of treatment has been reached .Remain with the resident for the treatment .Monitor for medication side effects, including rapid pulse, restlessness and nervousness throughout the treatment .Encourage the resident to cough and expectorate as needed .Administer therapy until it is gone .When treatment is complete, turn off nebulizer and disconnect T-piece, mouthpiece and medication cup .Obtain post-treatment pulse, respiratory rate and lung sounds . Event ID: Facility ID: 555711 If continuation sheet Page 4 of 4