Inspection·November 8, 2023

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some shift, during report, she heard RN1. RN1 stated (Resident1) was unresponsive and called for help, RN2 Called the code blue, (A medical emergency, where a resident requires immediate medical attention, most often the results of a respiratory or heart heart failure) went into (Resident1 ' s) room, she observed RT1 (Respiratory Therapist) Started CPR. RN2 further stated, she was across the hall from Resident1 ' s room, when the Code Blue was called, and Didn ' t hear the ventilator alarm go off, stating, No ventillator Alarms were going off. On [DATE], at 3:10 p.m., an interview was conducted with Respiratory Therapist (RT1), who stated, Resident1 was on full ventilator support (Requires the ventilator to breath). Nursing staff found (Resident1) unresponsive and called a code blue, and RT responded to the code. I was down the hall. The ventilator was not alarming on the monitor or in the room. RT1 Helped with CPR by doing compressions, until (First responders) showed up. RT1 further stated, At the beginning of the RT ' s shifts they do a vent check which includes checking the setting on the alarms, this check is done every 6 hours, and documented in the resident ' s progress notes (Medical records). On [DATE], at 12:55 p.m., an interview was conducted with the facilities Lead RT (LRT). The LRT stated, The (ventilator) alarm link is attatched to the side of the ventilator. I do a check (on ventilator alarms) every Monday for corporate, making sure everthing is plugged in, working properly, etc. Every RT comes on shift and checks their (Resident ' s ventilator) alarms by (visually) checking the parameters of the alarm, then (RT) begins their tracheostomy care, and when the resident is suctioned, the alarm will go off. The alarms are very loud. Ventilator alarm checks are done at the beginnning of shift and every 4 hours. (Alarm check documentation) is on Matrix under progress notes, and pop-ups (Flow sheets). A review of the facility ' s Policy & Procedure, titled, Mechanical Ventilation, undated, reference, RC2 0528.00, indicated, .Producedure . 3. The ventilator flowsheet will be maintained every four hours . 10. Check the ventilator alarms to be sure they are poroperly set before leaving the room and with every vent (ventilator) check (every four hours) . Documentation: On Ventilator Flow Sheet: Record ventilator checks, minimally every four hours . Review of Resident1 ' s RT progress notes, dated [DATE], (The date of the code blue) at 3:51 a.m., indicated, . Received patient . (Ventilator) alarms connected and audible . Review of Resident 1 ' s, Ventilator Flow Sheet, titled, Respiratory Therapy Minutes, dated [DATE], at 2:41 p.m., indicated, no documented ventilation alarm checks, every 4 hours. 2) On [DATE], at 1:45 p.m., an observation of Sub-Acute Unit, and ventilator alarms was conducted with SAC. Observed nursing staff monitoring ventilated residents from their bedside, visually checking their ventilator settings, and assisting residents with tracheostomy care. A ventillator was observed alarming in Resident 2s room. The Alarm was loud, a light lite up above resident ' s doorway, and Resident 2 ' s room number (3) was observed on a screen down in the hallway. SAC responded to the alarm immediately by suctioning resident (Clearing the airway of secretions or mucus), ventilator alarm continued to alert during suctioning, and reset by SAC, after care was performed. A review of Resident 2 ' s clinical records, face sheet was conducted, and indicated, Resident 2 was admitted to the facility on [DATE], with a diagnosis of Acute and chronic respiratory failure; Tracheostomy; On a Ventilator. Review of Resident 2 ' s RT progress notes, dated [DATE], indicated, . Patient received . Vent (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056229 If continuation sheet Page 2 of 3 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 056229 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Springs Healthcare & Rehabilitation Center 277 S Sunrise Way Palm Springs, CA 92262 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 alarms are connected and audible . Level of Harm - Minimal harm or potential for actual harm A review of Resident 2 ' s, ventilator flow sheet, titled, Respiratory Therapy Minutes, dated, [DATE], at 2:52, indicated, no documented ventilator alarm checks, every 4 hours, on the ventilator flow sheet. Residents Affected - Some A review of the facility ' s Policy & Procedure, titled, Mechanical Ventilation, undated, reference, RC2 0528.00, indicated, .Producedure . 3. The ventilator flowsheet will be maintained every four hours . 10. Check the ventilator alarms to be sure they are poroperly set before leaving the room and with every vent (ventilator) check (every four hours) . Documentation: On Ventilator Flow Sheet: Record ventilator checks, minimally every four hours . 3) On [DATE], at 2:25 p.m., an observation of Resident 3 conducted, which indicated, resident sleeping in bed, with a ventilator connected to his tracheostomy, resident ' s chest observed rising and falling with ventilator assistance. A review of Resident 3 ' s clinical records, face sheet was conduceted, and indicated, Resident 3 was admitted to the facility on [DATE], with a diagnosis of Acute respiratory failure; Dependance on ventilator. Review of Resident 3 ' s RT progress notes, dated, [DATE], at 2:31 a.m., indicated, Patient received . (Plus)5 alarms on and audible . A review of Resident 3 ' s, ventilator flow sheet, titled, Respiratory Therapy Minutes, dated [DATE], at 2:42 p.m., indicated, no documented ventilator alarm checks, every 4 hours. On [DATE], at 10:43 a.m., an interview was conducted with the facility ' s Administrator (Admin). Admin stated, she verified with the Sub-Acute Coordinator (SAC) that visual ventilator alarm checks are being performed by RT ' s every 4 hours, for every resident on a ventilator. Admin further verified, she had Reviewed the (RTs) progress notes, and ventilator alarm checks have been documented at the start of RTs shift, when they receive the residents care, but the alarm ventilator Checks are not being documented consistently (Every 4 hours), per facility policy and procedure (Mechanical Ventilation). A review of the facility ' s Policy & Procedure, titled, Mechanical Ventilation, undated, reference, RC2 0528.00, indicated, .Producedure . 3. The ventilator flowsheet will be maintained every four hours . 10. Check the ventilator alarms to be sure they are poroperly set before leaving the room and with every vent (ventilator) check (every four hours) . Documentation: On Ventilator Flow Sheet: Record ventilator checks, minimally every four hours . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056229 If continuation sheet Page 3 of 3