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Complaint Investigation

Community Care On Palm

November 25, 2025 · Riverside, CA · 4768 Palm Avenue
Citations 2
CMS Rating 4/5
Beds 51
Provider ID 555711
Healthcare Facility
Community Care On Palm
Riverside, CA  ·  View full profile →
Inspection Summary

COMMUNITY CARE ON PALM in RIVERSIDE, CA — inspection on November 25, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0657
Resident Assessment and Care Planning Deficiencies
Potential for More Than Minimal Harm

hospital/rehabilitation stay; and at least quarterly .

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/25/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Community Care on Palm

4768 Palm Avenue Riverside, CA 92501

SUMMARY STATEMENT OF DEFICIENCIES

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 .

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in RIVERSIDE, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from COMMUNITY CARE ON PALM or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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