Inspection Reports for
Palm Terrace Care Center
11162 Palm Terrace Ln, Riverside, CA 92505, United States, CA, 92505
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
9.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
143% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 11
Date: May 16, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, infection control, staffing, and facility environment at Palm Terrace Care Center.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity during meal service, delayed response to call lights, environmental maintenance issues such as peeled paint, inaccurate resident assessments, failure to provide timely audiology and dental consultations, insufficient nursing staff hours, lack of assistive eating devices, food safety and sanitation violations in the kitchen, infection control breaches including improper TB screening and PPE use, and pest infestations in the kitchen storage area.
Deficiencies (11)
Failure to ensure resident was treated with dignity and respect when lunch meal was not served at the same time as other residents.
Failure to ensure call lights were answered in a timely manner for six residents.
Failure to provide a comfortable homelike environment due to peeled paint on walls near residents' beds and bathroom door frame.
Failure to ensure Minimum Data Set (MDS) was accurately coded for hearing impairment.
Failure to ensure audiology consultation was provided for resident with hearing aid issues.
Failure to ensure sufficient nursing staff to meet residents' needs; CNA direct care service hours below required minimum on two days.
Failure to ensure dental consultation was provided for resident needing dentures.
Failure to provide assistive eating devices such as plate divider for resident with Parkinson's disease.
Failure to maintain food safety and sanitation in kitchen: pans stored wet with food debris and damaged bag of dry milk powder.
Failure to implement infection control practices: incomplete TB skin test screening, improper storage of incentive spirometer, and lack of PPE use by physical therapist.
Failure to maintain pest control in kitchen dry food storage: presence of roach, spider, ants, and spiderwebs.
Report Facts
Actual Total CNA Direct Care Service Hours: 2.36
Actual Total CNA Direct Care Service Hours: 2.32
Incentive Spirometer volume: 4000
Number of residents affected by call light delays: 6
Number of residents affected by peeled paint: 2
Number of residents affected by dignity meal service issue: 1
Number of residents affected by inaccurate MDS hearing coding: 1
Number of residents affected by audiology consultation failure: 1
Number of residents affected by dental consultation failure: 1
Number of residents affected by lack of assistive eating devices: 1
Number of residents affected by infection control breaches: 3
Number of residents affected by pest infestation: 67
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Named in dignity and meal service deficiency and call light delay findings |
| Director of Nursing | Director of Nursing (DON) | Named in multiple findings including dignity, call light delays, audiology, dental, staffing, infection control |
| Activity Director | Activity Director (AD) | Named in dignity and meal service deficiency |
| Certified Nursing Assistant 1 | CNA | Named in call light delay findings |
| Certified Nursing Assistant 2 | CNA | Named in call light delay findings |
| Registered Nurse 1 | RN | Named in call light delay and infection control findings |
| Maintenance Supervisor | Maintenance Supervisor (MS) | Named in environmental deficiency regarding peeled paint |
| Administrator | Administrator (ADM) | Named in environmental deficiency regarding peeled paint |
| MDS Nurse | MDS Nurse | Named in inaccurate MDS coding deficiency |
| Social Service Director | SSD | Named in audiology and dental consultation deficiencies |
| Director of Staff Development | DSD | Named in staffing deficiency |
| Facility Dentist | Facility Dentist (FD) | Named in dental consultation deficiency |
| Director of Rehabilitation | DOR | Named in assistive eating device deficiency |
| Dietary Supervisor | DS | Named in food safety and sanitation deficiencies |
| Registered Dietitian 1 | RD 1 | Named in food safety and pest control deficiencies |
| Registered Dietitian 2 | RD 2 | Named in food safety and sanitation deficiencies |
| Infection Preventionist | IP | Named in infection control deficiencies |
| Physical Therapist | PT | Named in infection control deficiency for not wearing PPE |
Inspection Report
Routine
Deficiencies: 8
Date: May 10, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, medication storage, food and nutrition services, therapeutic diets, infection control, and sanitation in the facility.
Findings
The facility was found deficient in multiple areas including failure to maintain accessible advance directives, improper medication storage in emergency kits, inadequate food preparation and dietary services including failure to provide prescribed pureed diets and honor food preferences, unsafe and unsanitary kitchen conditions, and failure to follow infection control practices during wound care.
Deficiencies (8)
Failed to ensure a copy of the Advance Directive was available in the resident's record and accessible to staff for one resident.
Medications in emergency medication supply containers (EKITs) were not compartmentalized properly, with multiple different medications mixed in each compartment.
Food service workers did not follow the facility's cleaning procedure to clean food preparation surfaces and stationary equipment.
Residents on physician-prescribed pureed diets received chunky noodles instead of smooth pureed food, risking aspiration and choking.
A resident did not receive milk and pureed soup as per food preference, risking decreased food intake and weight loss.
Resident with pureed diet order was served regular texture salad and received a nutritional supplement with fewer calories than ordered.
Multiple unsafe and unsanitary kitchen conditions including cracked tiles, missing grout, peeling paint, rusted shelves, grease buildup on fire hoods, dirty microwave, dusty grid divider, buildup on ice machine pipes, and chipped paint on refrigerator shelves.
Treatment Nurse failed to change gloves and perform hand hygiene during wound care for one resident, risking cross-contamination and infection.
Report Facts
Medications in EKIT #1: 48
Medications in EKIT #2: 40
Residents affected by pureed diet failure: 10
Residents affected by food preference failure: 1
Residents affected by wound care infection control failure: 1
Cracked tiles: 5
Storage shelves rusted: 4
Chipped paint shelves: 7
Residents sampled for food service: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant 1 | CNA | Interviewed regarding Resident 39's meal tray and food preference not honored |
| Dietary Supervisor | DTR | Interviewed multiple times regarding food service failures, medication storage, and kitchen sanitation |
| Consultant Pharmacist | CP | Interviewed regarding medication storage in EKITs |
| Registered Dietitian 2 | RD 2 | Interviewed regarding dietary failures, food texture, and kitchen sanitation |
| Registered Dietitian 3 | RD 3 | Interviewed regarding cleaning procedures in kitchen |
| Director of Nursing | DON | Interviewed regarding dietary supplement error and wound care infection control |
| Treatment Nurse | TN | Observed and interviewed regarding failure to change gloves and perform hand hygiene during wound care |
| Director of Staff Development | DSD | Interviewed regarding dietary tray checks and risk of aspiration |
| Maintenance Supervisor | MTD | Interviewed regarding rusted shelves and ice machine buildup |
| Activities Supervisor | AS | Observed and interviewed regarding incorrect meal served to Resident 32 |
| Activities Assistant | AA | Observed and interviewed regarding incorrect meal served to Resident 32 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 10, 2023
Visit Reason
An unannounced visit was conducted on July 10, 2023, to investigate a complaint alleging the release of 800 pages of wrong resident medical records to an unauthorized person.
Complaint Details
The complaint involved the release of 800 pages of wrong resident medical records to an unauthorized person. The complaint was substantiated based on the investigation findings.
Findings
The facility failed to safeguard resident-identifiable medical records, resulting in the inadvertent release of wrong resident records due to residents having the same last name. The Medical Record Director and Director of Nursing acknowledged procedural failures and chaotic conditions contributing to the error.
Deficiencies (1)
Failure to safeguard resident-identifiable information and/or maintain medical records on each resident in accordance with accepted professional standards, resulting in the release of wrong resident records.
Report Facts
Pages of wrong resident medical records released: 800
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medical Record Director | Interviewed regarding the release of wrong resident records and described the process and errors | |
| Director of Nursing | DON | Interviewed about the incident and prevention measures |
Inspection Report
Routine
Deficiencies: 6
Date: May 25, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, respiratory care, pharmacy services, and kitchen sanitation at Palm Terrace Care Center.
Findings
The facility was found deficient in multiple areas including failure to identify, assess, and monitor skin discolorations in residents, improper maintenance of oxygen humidifiers, medication administration errors including mislabeling and lack of policies for sterile compounding, presence of non-emergency narcotic patches in emergency kits, and unsanitary kitchen utensils posing risk of cross contamination.
Deficiencies (6)
Failure to ensure skin discolorations were identified, addressed, and monitored for three residents.
Failure to ensure the humidifier was changed according to facility policy for one resident receiving oxygen.
Medication administration error where one medication was labeled with another resident's name.
Lack of facility policy and staff education on safe use of compounded sterile preparations (CSPs).
Consultant Pharmacist was unaware of potent narcotic transdermal patches present in the facility's emergency kit which are not considered for emergency use.
Failure to ensure kitchen utensils were clean and in safe operating condition, risking cross contamination and foodborne illness.
Report Facts
Residents affected: 3
Oxygen flow rate: 2
Medication administration error: 1
TPN infusion rate: 90
Number of fentanyl patches in emergency kit: 4
Number of residents consuming food from kitchen: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Interviewed regarding failure to identify and document skin discolorations for Residents 10, 32, and 44 |
| LVN 50 | Licensed Vocational Nurse | Observed preparing medication with incorrect labeling and acknowledged the error |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed about skin assessment policies and lack of documentation for skin discolorations |
| Director of Staff Development | Director of Staff Development (DSD) | Interviewed about humidifier sticker change policy |
| Pharmacist-In-Charge | Pharmacist-In-Charge (PIC) | Interviewed regarding compounding practices and policies |
| Consultant Pharmacist | Consultant Pharmacist (CP) | Interviewed about sterile compounding education and emergency kit contents |
| Registered Nurse Supervisor | Registered Nurse Supervisor (RNS) | Interviewed about compounding practices and medication room inspection |
| Dietary Supervisor | Dietary Supervisor (DS) | Interviewed regarding unsanitary kitchen utensils |
| Infection Preventionist | Infection Preventionist (IP) | Interviewed about humidifier maintenance policy |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 27, 2023
Visit Reason
An unannounced visit was conducted on March 27, 2023, due to a quality of care concern regarding the provision and documentation of respiratory care and oxygen therapy for residents.
Complaint Details
The visit was complaint-related, triggered by concerns about quality of care in respiratory therapy. The deficiencies were substantiated with findings of inadequate documentation and lack of physician orders for oxygen therapy.
Findings
The facility failed to ensure proper documentation and physician orders for oxygen therapy for four residents. Licensed staff did not consistently document PRN oxygen use or the rationale for oxygen administration, and one resident was receiving oxygen without a physician's order. These failures posed a risk of inconsistent respiratory care and potential untreated changes in residents' respiratory status.
Deficiencies (2)
Failure to properly document residents' use of PRN oxygen for three of four residents reviewed.
Failure to ensure oxygen was administered with a physician's order for one resident.
Report Facts
Oxygen flow rates: 2
Oxygen flow rates: 3
Date of survey completion: May 1, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) 1 | Provided care to Resident 4 and stated Resident 4 wore oxygen continuously but was unsure of duration | |
| Licensed Vocational Nurse (LVN) 1 | Stated PRN medication including oxygen must be documented in eMAR and progress notes; noted lack of documentation and physician order for Resident 4 | |
| Licensed Vocational Nurse (LVN) 2 | Stated PRN medication must be documented; noted lack of documentation for Resident 2 and lack of physician order for Resident 4 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 10, 2023
Visit Reason
An unannounced visit was conducted on January 10, 2023, to investigate an issue regarding a resident's rights related to access to medical records.
Complaint Details
The complaint investigation was related to a resident's rights issue concerning the delay in providing requested medical records. The Medical Record Director stated the facility had not processed the request received on December 26, 2022, within the required timeframe.
Findings
The facility failed to provide copies of requested medical records for one of three residents reviewed (Resident 1) within two days of the request, resulting in a delay in acquiring Resident 1's medical records.
Deficiencies (1)
Failure to provide copies of requested medical records for Resident 1 within two days of the request.
Report Facts
Residents affected: 3
Days delay: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medical Record Director | Interviewed regarding delay in processing medical records request |
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