Other·January 23, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated standard survey for the investigation of one complaint. Complaint number CA00609754. Representing the California Department of Public Health: Surveyor Federal ID number 33235, HFEN. The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for complaint number CA00609574.

F623 SS=D Notice Requirements Before Transfer/Discharge CFR(s): 483.15(c)(3)-(6)(8)

F623 12/19/2018 §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State LongLABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JLCD11 Facility ID: CA240000033 If continuation sheet 1 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056428 (X3) DATE SURVEY COMPLETED 12/10/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CALIFORNIA NURSING & REHABILITATION CENTER 2299 N Indian Canyon Dr Palm Springs, CA 92262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Term Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JLCD11 Facility ID: CA240000033 If continuation sheet 2 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056428 (X3) DATE SURVEY COMPLETED 12/10/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CALIFORNIA NURSING & REHABILITATION CENTER 2299 N Indian Canyon Dr Palm Springs, CA 92262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JLCD11 Facility ID: CA240000033 If continuation sheet 3 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056428 (X3) DATE SURVEY COMPLETED 12/10/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CALIFORNIA NURSING & REHABILITATION CENTER 2299 N Indian Canyon Dr Palm Springs, CA 92262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure notification of transfer to an acute care facility was provided to a representative of the Office of the State LongTerm Care Ombudsman for three of three sampled residents (Resident 1, Resident 2, and Resident 3). This failure increased the potential for Resident 1,Resident 2, and Resident 3 to not have an advocate to ensure a safe and effective transition of care to the acute care facility. Findings: On October 30, 2018, at 10:00 a.m., an unannounced visit was made to the facility for the investigation of one complaint. On October 30, 2018, Resident 1's medical record was reviewed. Resident 1 was admitted to the facility on October 19, 2018, with diagnoses which included cerebral infarction with right sided paralysis (stroke), aphasia (inability to speak), and dysphagia (inability to safely swallow food and liquids) The Progress Record, dated October 23, 2018, at 11:45 am, indicated, "...ordered to transfer pt (patient) to the hospital." There was no documented evidence a representative of the Office of the State LongFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JLCD11 Facility ID: CA240000033 If continuation sheet 4 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056428 (X3) DATE SURVEY COMPLETED 12/10/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CALIFORNIA NURSING & REHABILITATION CENTER 2299 N Indian Canyon Dr Palm Springs, CA 92262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Term Care Ombudsman was notified of Resident 1's transfer to the acute care facility. On October 30, 2018, Resident 2's medical record was reviewed. Resident 2 was admitted to the facility on October 8, 2018, with diagnoses which included right ankle fracture. The Progress record, dated October 24, 2018, at 11:30 a.m., indicated, " Patient will not come back today after surgery." There was no documented evidence a representative of the Office of the State LongTerm Care Ombudsman was notified of Resident 2's transfer to the acute care facility. On October 30, 2018, Resident 3's medical record was reviewed. Resident 3 was admitted to the facility on October 10, 2018, with metabolic encephalopathy (brain disease causing altered mental function). The Progress Record, dated October 29, 2018, at 9:00 p.m., indicated, "...new order to send out to ER (emergency room) for evaluation due to ALOC (altered level of consciousness) and hypotension (low blood pressure)." There was no documented evidence a representative of the Office of the State LongTerm Care Ombudsman was notified of Resident 3's transfer to the acute care facility. On October 30, 2018, at 11:25 a.m., an interview was conducted with Social Services FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JLCD11 Facility ID: CA240000033 If continuation sheet 5 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056428 (X3) DATE SURVEY COMPLETED 12/10/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CALIFORNIA NURSING & REHABILITATION CENTER 2299 N Indian Canyon Dr Palm Springs, CA 92262 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Director (SSD). The SSD stated she did not notify the Ombudsman office of the transfer to the acute care facility for Residents 1, 2, and 3. The SSD stated she was unaware the Ombudsman should be notified of transfers to the acute care facility. On October 30, 2018, at 11:30 a.m., the Director of Nursing (DON) was interviewed regarding Ombudsman notification of transfers to acute care facilities. The DON stated she was unaware of the requirement to notify the Ombudsman of transfers to the acute care facilities. On October 30, 2018, at 11:33 am, the DON was asked for the facility policy and procedure (P&P) related to notifying the Ombudsman of resident transfers and discharges. The DON stated the facility does not have a P&P related to notifying the Ombudsman of resident transfers and discharges. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JLCD11 Facility ID: CA240000033 If continuation sheet 6 of 6