Inspection·May 7, 2024

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide resident with an alternative meal, consistent with resident's identified food allergies, for 1 out of 5 residents (Resident 1). This failure could have negatively impacted Resident 1's health by consuming a food item they had an allergy to. Findings: On May 7, 2024, at 7:55 a.m., an unannounced visit was made to the facility to investigate a quality-of-care issue. On May 7, 2024, at 8:20 a.m., an interview was conducted with Resident 1, who stated, her food allergies are peanuts and tomatoes. Resident further stated, she requested a tuna sandwich from nursing staff, and nursing staff brought her a tuna sandwich with tomatoes on it. Resident 1 informed nursing staff she was allergic to tomatoes, and she could not eat it. Nursing staff returned resident's sandwich and brought her a new tuna sandwich with no tomatoes on it. A review of Resident 1's face sheet, indicated, resident was admitted to the facility on [DATE], with a diagnosis of Pneumonitis (inflammation in the lungs) due to inhalation of food and vomit. Further review, indicated, Resident 1 had food allergies to peanuts and tomatoes. A review of Resident 1's Brief Interview for Mental Status ({BIMS} – an assessment tool used to identify cognitive conditions) indicated a score of 12 (moderate cognitive impairment). On May 7, 2024, at 11:10 a.m., an interview was conducted with Certified Nursing Assistant (CNA) 1, who stated, when a resident requests an alternative food item, such as a sandwich, the CNA will take resident's Diet Card (a card on residents meal trays that contains individualized diet information, including food allergies) off resident's meal tray, check resident's allergies and diet against their food request, give dietary staff residents diet card and food request, dietary staff checks resident's food allergy on diet card, then will give nursing staff resident's food item, if available per diet/food allergies. On May 7, 2024, at 1:00 p.m., an interview was conducted with facility [NAME] 1, who stated, when a resident requests an alternative food item, nursing staff provides resident diet card to dietary staff, dietary staff will check resident's diet card against resident's food allergies and request, if diet card is not available, [NAME] 1 will ask nursing staff to verify residents allergies from (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 2 Event ID: 056229 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 05/07/2024 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)