Other·February 8, 2018

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 the investigation of an entity reported incident: Entity Reported Incident Number CA00544981. Representing the California Department of Public Health: Surveyor 37626, HFEN The inspection was limited to the specific entity-reported incident investigation and does not represent the findings of a full inspection of the facility. This Department was able to substantiate a violation of the regulations for entity reported incident number CA00544981.

F226 SS=D DEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES CFR(s): 483.12(b)(1)-(3), 483.95(c)(1)-(3)

F226 07/19/2017 483.12 (b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations, and (3) Include training as required at paragraph §483.95, LABORATORY 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: EX6Z11 Facility ID: CA240000039 If continuation sheet 1 of 4 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: _______________ 056328 (X3) DATE SURVEY COMPLETED 09/08/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PREMIER CARE CENTER FOR PALM SPRINGS 2990 E Ramon Rd Palm Springs, CA 92264 (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 483.95 (c) Abuse, neglect, and exploitation. In addition to the freedom from abuse, neglect, and exploitation requirements in § 483.12, facilities must also provide training to their staff that at a minimum educates staff on(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at § 483.12. (c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property (c)(3) Dementia management and resident abuse prevention. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to implement the policy and procedure for abuse prevention by ensuring: 1. Resident 1 was assessed and monitored after an allegation of abuse: 2. An investigation of the alleged incident of abuse was completed; and, 3. An allegation of abuse was reported to the Department, police, and Ombudsman. These facility failures increased the potential for the Resident to have physical and psychological injuries that were undetected and untreated. Findings: On July 20, 2017, Resident 1's record was reviewed. A social services note dated June FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EX6Z11 Facility ID: CA240000039 If continuation sheet 2 of 4 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: _______________ 056328 (X3) DATE SURVEY COMPLETED 09/08/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PREMIER CARE CENTER FOR PALM SPRINGS 2990 E Ramon Rd Palm Springs, CA 92264 (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 14, 2017, at 11: 45 a.m., indicated, "This resident daughter came to SSD (Social Service Director) office stating that this resident is stating that someone had grab (sic) her by the right arm. This resident states that she doesn't remember who did it or what time it happen (sic). This resident states that she notify (sic) the nursing staff of this. Per nursing staff they don't have any report of this happening...This resident nurse and DON (Director of Nurses) has been notify (sic) of what this resident and daughter are saying. We will continue to investigate this and to monitor (sic) the situation..." During an interview conducted with the SSD on July 20, 2017, at 11 a.m., the SSD stated he told the DON about the alleged abuse. The Administrator, DON, and Administrator in Training (AIT), were interviewed on July 20, 2017, at 2:35 p.m. The administration confirmed there was no investigation conducted for the incident of alleged abuse and the alleged abuse incident was not reported to the Department per regulation. The facility policy and procedure titled, "Abuse Prevention," was reviewed on July 20, 2017. The policy indicated: "It is the policy for this facility that each resident has the right to be free from abuse..." "...Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, resident representatives, families, friends, or other individuals." "...All identified events are reported to the Administrator/Designee immediately and will be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EX6Z11 Facility ID: CA240000039 If continuation sheet 3 of 4 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: _______________ 056328 (X3) DATE SURVEY COMPLETED 09/08/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PREMIER CARE CENTER FOR PALM SPRINGS 2990 E Ramon Rd Palm Springs, CA 92264 (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 thoroughly investigated." "... When an incident or allegation of resident abuse or injury of an unknown source is identified, the Administrator/Designee will initiate an investigation..." "... All alleged violations will be reported via phone or in writing within 24 hours to the State Licensing Agency. The facility shall follow- up to the State Licensing Agency in writing the findings and results of the completion of the investigation within 5 days..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EX6Z11 Facility ID: CA240000039 If continuation sheet 4 of 4