Other·September 20, 2018

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 annual Re-certification Survey on June 26, 2018 to June 29, 2018. Representing the California Department of Public Health: 37626, HFEN; 32192, HFEN; 36779, HFEN; and 38477, HFEN. The facility census was 94. The sample size was 22 residents.

F578 SS=D Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir CFR(s): 483.10(c)(6)(8)(g)(12)(i)-(v)

F578 07/29/2018 §483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. §483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate. §483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or 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: 7S0J11 Facility ID: CA240000039 If continuation sheet 1 of 35 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 06/29/2018 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 refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. (ii) This includes a written description of the facility's policies to implement advance directives and applicable State law. (iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. (iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law. (v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the residents were provided written information to complete an advance directive (a written statement of a person's wishes regarding his/her medical treatment) for two of 22 sampled residents (Residents 236 and 60). This failure had the potential for Residents 236 and 60 to not make their wishes regarding their medical treatment known. Findings: 1. On June 27, 2018, the record of Resident 236 was reviewed. Resident 236 was admitted to the facility on June 19, 2018, with diagnoses FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7S0J11 Facility ID: CA240000039 If continuation sheet 2 of 35 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 06/29/2018 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 which included urinary tract infection and acute pyelonephritis (infection of the kidney.) There was no documented evidence the facility provided Resident 236 information about advance directive. On June 28, 2018, at 11: 25 a.m., Resident 236 was observed lying in bed, alert, and verbally responsive. During a concurrent interview, Resident 236 stated the facility did not provide her information about advance directives. The record of Resident 236 was reviewed with the Social Worker (SW) on June 29, 2018, at 4:17 p.m. During a concurrent interview, the SW acknowledged information about advance directives was not provided to Resident 236. The SW stated Resident 236 should have been provided with information about advance directive. 2. On June 27, 2018, the record of Resident 60 was reviewed. Resident 60 was admitted to the facility on May 21, 2018, with diagnoses which included dysphagia (difficulty swallowing). The Physician Orders for Life-Sustaining Treatment (POLST), dated May 21, 2018, indicated, "...Patient Has Capacity...No Advance Directive..." There was no documented evidence the facility provided information about advance directive to Resident 60. On June 28, 2018, at 10:18 a.m., Resident 60 was interviewed. He stated he was not provided information about advance directive. On June 29, 2018, at 10:36 a.m., the record of Resident 60 was reviewed with the SW. During FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7S0J11 Facility ID: CA240000039 If continuation sheet 3 of 35 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 06/29/2018 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 a concurrent interview, the SW stated Resident 60 was not provided with information about advance directives. The SW stated Resident 60 should have been given information about advance directive. The facility's policy titled, "...Subject: Advance Directives," revised May 5, 2007, was reviewed. The policy indicated: "...It is the policy of this facility that a resident's choice about advance directives will be respected..." The policy did not indicate the facility procedure when a resident did not have an advanced directive.

F609 SS=D Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4)

F609 07/29/2018 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7S0J11 Facility ID: CA240000039 If continuation sheet 4 of 35 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 06/29/2018 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 §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on obsevation, interview, and record review, the facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) for one of one sampled resident (Resident 10) when Resident 10 alleged another resident (Resident 14) was abusive to him. This failure caused the allegation of abuse to not be investigated by CDPH and increased the potential to place the residents at risk for harm. Findings: On June 27, 2018, at 3:15 p.m., Resident 10 was observed in his room in a wheelchair. Resident 10 was observed to have a below the knee amputation (surgical removal of the lower limb) of his right leg, and a dressing wrapped around his left foot and ankle. In a concurrent interview, Resident 10 stated beginning in April 2018, there were four incidents in which Resident 14 was aggressive towards him. Resident 14 stated in one of the incidents, Resident 14 came to his room and blocked him from exiting the room. Resident 10 stated he told the Operations Manager (OM) about the incident. Resident 10 stated after he told the OM about FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7S0J11 Facility ID: CA240000039 If continuation sheet 5 of 35 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 06/29/2018 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 that incident, he was at a table on the smoking patio when Resident 14 approached the table and stated to him, "You know what happens to snitches where I came from? They get stabbed." Resident 10 stated Resident 14 made him feel like he had to "look over his shoulder." When asked if anyone from the CDPH was out to see him about the incident and ask him questions, Resident 10 stated, "No." On June 28, 2018, Resident 10's record was reviewed. Resident 10 was admitted to the facility on March 15, 2018, with diagnoses including sepsis (infection in the blood), diabetes mellitus (high blood sugar), cellulitis (redness and swelling of the skin), abscess (swelling with an accumulation of pus) of tendon sheath (the membrane around the tendon) of the left ankle and foot, and osteomyelitis (infection of the bone). Resident 10's Minimum Data Set (MDS - an assessment tool), dated June 24, 2018, indicated his "Brief Interview for Mental Status (BIMS - a cognitive assessment)" score was 15 (on a scale of 0-15, with 15 indicating Resident 10 was cognitively intact). On June 29, 2018, at 7:50 a.m., an interview was conducted with the OM. The OM confirmed Resident 10 alleged an incident of Resident 14 blocking his way. The OM confirmed another incident in which Resident 10 alleged Resident 14 said to him, "You know what they do to rats in prison? They shive them." When asked what the term "shive" meant, the OM stated it was a prison term meaning "stab." The OM stated Resident 10 "was so upset about it" he had to call the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7S0J11 Facility ID: CA240000039 If continuation sheet 6 of 35 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 06/29/2018 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 police. When asked if he reported the allegation to the CDPH, the OM stated, "No." On June 29, 2018, at 8:35 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated there were "so many" incidents involving Resident 10 and Resident 14. The DON confirmed there was an incident involving Resident 10 and Resident 14 that occurred on the smoking patio. On June 29, 2018, at 9:15 a.m., an interview was conducted with the OM. The OM stated the incident involving the alleged statement Resident 14 made to Resident 10 occurred on May 25, 2018. The OM confirmed he should have reported the incident to the CDPH. On June 29, 2018, the facility policy and procedure titled, "Reporting Alleged Violations of Abuse...or Mistreatment," revised November 28, 2017, was reviewed. The policy indicated, "...It is the policy of this Facility that each resident has the right to be free from abuse...and mistreatment...Residents must not be subjected to abuse by anyone, including...other residents...In response to allegations of abuse...or mistreatment, the Facility will...Ensure that all alleged violations involving abuse...or mistreatment...are reported immediately but...Not later than two (2) hours after the allegation is made if the events that cause the allegation involves abuse...Ensure that all alleged violations involving abuse, or mistreatment...are reported to...The State Survey Agency...Ensure that the results of all investigations are reported within five (5) working days of the incident to...The State Survey Agency..."

F623 Notice Requirements Before FORM CMS-2567(02-99) Previous Versions Obsolete

F623 Event ID: 7S0J11 07/29/2018 Facility ID: CA240000039 If continuation sheet 7 of 35 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 06/29/2018 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) SS=D Transfer/Discharge CFR(s): 483.15(c)(3)-(6)(8) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §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 LongTerm 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7S0J11 Facility ID: CA240000039 If continuation sheet 8 of 35 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 06/29/2018 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 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 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7S0J11 Facility ID: CA240000039 If continuation sheet 9 of 35 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 06/29/2018 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 §483.15(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). This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure proper notification of transfer or discharge was provided to the residents or the residents' representative and the office of the state long-term care ombudsman for two of 22 sampled residents (Residents 7 and 41) when: 1. For Resident 7, there was no documented evidence a proposed notice of discharge was provided to the resident and to the ombudsman; and 2. For Resident 41, there was no documented evidence a written proposed notice of transfer was provided to the resident and to the ombudsman. These failures caused Residents 7 and 41 to not be aware of the circumstances related to their transfer or discharge, the information about the appeal process and their appeal rights, and the contact information of the ombudsman. This failure also increased the potential for to the ombudsman to not be aware of the Residents 7 and 41's transfer or discharge. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7S0J11 Facility ID: CA240000039 If continuation sheet 10 of 35 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 06/29/2018 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 Findings: 1. On June 29, 2018, at 8:38 a.m., Resident 7's record was reviewed with the Minimum Data Set (MDS-an assessment tool) Nurse (MDSN). Resident 7 was originally admitted to the facility on June 15, 2016, with diagnoses which included non-pressure chronic ulcer (wound) of right lower leg. The document titled, "Progress Notes," indicated,"... May 11, 2018, at 16:17, (4:17 p.m.) Type: Discharge SummaryNursing...Reason for Discharge: The resident is being discharged due to: Patient has scheduled surgery..." There was no documented evidence Resident 7 received a written notice of transfer or discharge. During a concurrent interview with the MDSN, the MDSN stated Resident 7 was transferred to the acute hospital twice. The MDSN stated Resident 7 was transferred on April 27, 2018, for surgical evaluation and returned to the facility on April 29, 2018, and on May 11, 2018, for surgery and was re-admitted back to the facility on May 12, 2018, after a stay of more than 24 hours at the acute hospital. The MDSN stated she could not find documentation the written proposed notice of transfer was provided to Resident 7 for the two occasions of transfer/discharge. On June 29, 2018, at 8:55 a.m., the Social Worker (SW) was interviewed. The SW confirmed there was no written proposed notice of transfer or discharge completed and given to Resident 7 and to the ombudsman for the two occasions Resident 7 was transferred/discharged to the hospital. The SW FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7S0J11 Facility ID: CA240000039 If continuation sheet 11 of 35 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 06/29/2018 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 stated the proposed notice of transfer or discharge should have been completed and a copy should have been provided to Resident 7 and to the ombudsman. 2. On June 29, 2018, at 9:51 a.m., Resident 41's record was reviewed with the MDSN. Resident 41 was originally admitted to the facility on July 30, 2017, with diagnoses which included pneumonia (lung infection). The physician order, dated March 28, 2018, at 4:50 a.m., indicated, "SEND TO (NAME OF THE ACUTE HOSPITAL) FOR FURTHER EVALUATION..." During a concurrent interview, the MDSN stated Resident 41 had a change in condition and was transferred to the acute hospital on March 28, 2018. The MDSN stated Resident 41 was re-admitted back to the facility on April 2, 2018. The MDSN stated she could not find any documented evidence a written notice of transfer was completed and given to the resident or representative and to the ombudsman for Resident 41's transfer to the acute hospital. On June 29, 2018, at 9:55 a.m., the SW was interviewed. The SW confirmed there was no written proposed notice of transfer completed and provided to Resident 41 for the resident's transfer on March 28, 2018. The SW further stated a copy of written proposed notice of transfer should have been given to Resident 41 and to the ombudsman. The facility's policy titled, "Criteria for Transfer and Discharge," revised November 2016, was reviewed. The policy did not include the requirement for the facility to provide a written FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7S0J11 Facility ID: CA240000039 If continuation sheet 12 of 35 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 06/29/2018 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 copy of the proposed notice of transfer/discharge to the residents or the residents' representative and to the ombudsman.

F655 SS=E Baseline Care Plan CFR(s): 483.21(a)(1)-(3)

F655 07/29/2018 §483.21 Comprehensive Person-Centered Care Planning §483.21(a) Baseline Care Plans §483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must(i) Be developed within 48 hours of a resident's admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to(A) Initial goals based on admission orders. (B) Physician orders. (C) Dietary orders. (D) Therapy services. (E) Social services. (F) PASARR recommendation, if applicable. §483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan(i) Is developed within 48 hours of the resident's admission. (ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section). §483.21(a)(3) The facility must provide the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7S0J11 Facility ID: CA240000039 If continuation sheet 13 of 35 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 06/29/2018 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 resident and their representative with a summary of the baseline care plan that includes but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident's medications and dietary instructions. (iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (iv) Any updated information based on the details of the comprehensive care plan, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure a copy of the baseline care plan summary was provided to the residents or residents' representative for nine of 22 sampled resident (Residents 28, 60, 54, 236, 56, 7, 41, 85, and 86). This failure increased the potential for the residents to not be able to understand and participate in their initial goals and plans of care. Findings: 1. On June 27, 2018, at 9:51 a.m., Resident 28 was observed sitting beside her bed on a wheelchair. Resident 28's lower legs were observed to be swollen. On June 29, 2018, at 8:57 a.m., Resident 28 was interviewed with an interpreter. She stated she did not receive a copy of the baseline care plan summary. On June 29, 2018, the record of Resident 28 was reviewed. The record indicated she was admitted to the facility on April 17, 2018, with diagnoses which included acute embolism FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7S0J11 Facility ID: CA240000039 If continuation sheet 14 of 35 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 06/29/2018 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 (obstruction of blood vessel), thrombosis (blood clot) of unspecified vein, hypertension (high blood pressure), osteoarthritis (inflammation of the joints), pain, and type 2 diabetes mellitus (high blood sugar). There was no documented evidence the facility provided a copy of the baseline care plan summary to Resident 28. 2. On June 26, 2018, at 12:20 p.m., Resident 60 was observed lying in bed. A tube feeding (liquid nutrition) bottle was observed hanging on a pole by Resident 60's bedside. During a concurrent interview with Resident 60, he stated he did not receive a copy of his baseline care plan summary. On June 29, 2018, the record of Resident 60 was reviewed. The record indicated he was admitted to the facility on May 21, 2018, with diagnoses which included dysphagia (difficulty swallowing), urinary tract infection, anxiety disorder (mood disorder), bipolar disorder (mood disorder), adult failure to thrive (failure to gain weight), and convulsions. There was no documented evidence the facility provided Resident 60 a copy of his baseline care plan summary. 3. On June 27, 2018, at 10:55 a.m., Resident 54 was observed lying in bed. Resident 54 was observed to have a foley catheter (plastic tube inserted to the bladder drain urine). During a concurrent interview with Resident 54, he stated he could not urinate on his own. He further stated he was not given a copy of the baseline care plan summary. Resident 54 stated, "I do not know what it is all about." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7S0J11 Facility ID: CA240000039 If continuation sheet 15 of 35 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 06/29/2018 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 The record of Resident 54 was reviewed on June 29, 2018. The record indicated Resident 54 was admitted to the facility on May 15, 2018, with diagnoses which included acute kidney failure (kidney disorder), hypertension, acute respiratory failure (lung disorder), dementia (memory loss), benign prostatic hyperplasia (enlargement of the prostate), cerebral infarction (stroke), major depressive disorder (mood disorder), and type 2 diabetes mellitus. There was no documentation in Resident 54's record a copy of the baseline care plan summary was provided to the resident. 4. On June 27, 2018, at 12:06 p.m., Resident 236 and her family member (FM) were interviewed. Resident 236 and FM stated they were not given a copy of the baseline care plan summary. On June 28, 2018, at 11:25 a.m., Resident 236 was observed lying in bed. Resident 236 had a foley catheter and a nephrostomy bag (a tube inserted into the kidneys to drain fluids) lying beside her. On June 29, 2018, the record of Resident 236 was reviewed. Resident 236's record indicated she was admitted to the facility on June 19, 2018, with diagnoses which included urinary tract infection, acute pyelonephritis (infection of the kidney), major depressive disorder, anxiety disorder, hypertension, myocardial infarction (heart attack), cardiac arrythmia (irregular heart beat), and cerebral infarction. There was no documented evidence a copy of the baseline care plan summary was provided to the resident or the resident representative. 5. On June 27, 2018, 12:38 p.m., an interview FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7S0J11 Facility ID: CA240000039 If continuation sheet 16 of 35 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 06/29/2018 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 was conducted with Resident 56. When asked if the facility gave her a written summary of her plan of care after she was admitted, she stated, "No, no discussion or paper about a plan of care." On June 28, 2018, at 4:15 p.m., a review of Resident 56's record was conducted. Resident 56 was admitted to the facility on May 25, 2018, with diagnoses including embolism and thrombosis, malignant neoplasm (cancer) of the ovary, anxiety disorder, hypertension, pleural effusion (fluid in the lungs), gastroesophageal reflux disease with esphagitis (heart burn with inflammation of the esophagus), pain, and edema (swelling). There was no documented evidence a copy of the summarized baseline plan of care was given to Resident 56. The Quality Assurance Nurse (QAN) was interviewed on June 28, 2018, at 10:17 a.m. The QAN stated the facility did not provide the residents or the residents' representatives a copy of the baseline care plan because the facility was not aware the facility was required to give a copy to them. 6. On June 29, 2018, at 8:38 a.m., Resident 7's record was reviewed with the Minimum Data Set (MDS-an assessment tool) Nurse (MDSN). Resident 7 was originally admitted to the facility on June 15, 2016, with diagnoses which included non-pressure chronic ulcer (wound) of right lower leg, alcohol abuse, bipolar disorder, major depressive disorder, anxiety disorder, seizures, hypertension, myocardial infarction, chronic obstructive pulmonary disease (lung disease), gastro-esophageal reflux disease with espohagitis, peptic ulcer (stomach ulcer), non-pressure chronic ulcer of the right foot (wound), cardiac murmur (abnormal heart sound), and pain. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7S0J11 Facility ID: CA240000039 If continuation sheet 17 of 35 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 06/29/2018 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 There was no documented evidence in Resident 7's record a written copy of the baseline care plan was provided to Resident 7 or to Resident 7's representative. During a concurrent interview with the MDSN she confirmed there was no documented evidence Resident 7 and/or her representative were given a written copy of the baseline care plan. 7. On June 29, 2018, at 9:51 a.m., Resident 41's record was reviewed with the MDSN. Resident 41 was originally admitted to the facility on July 30, 2017, with diagnoses which included hypertension, mood disorder, hypothyroidism (thyroid disorder), hypoglycemia (low blood sugar), dementia, major depressive disorder, seizures, cerebral infarction, hepatic failure (liver disorder), chronic kidney disease (kidney disorder), pain, and acquired absence of right leg above knee, and pneumonia (lung infection). There was no documented evidence a copy of the baseline care plan summary was provided to Resident 41 or to her representative. In a concurrent interview with the MDSN, she confirmed she could not find any documented evidence a written copy of the baseline care plan summary was provided to Resident 41 or her representative. 8. On June 29, 2018, at 8:04 a.m., Resident 85's record was reviewed with the MDSN. Resident 85 was admitted to the facility on April 9, 2018, with diagnoses which included chronic respiratory failure (inadequate gas exchange by the lungs), abnormalities of gait and mobility, insomnia (difficulty sleeping), hypertension, atrial fibrillation (irregular heart FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7S0J11 Facility ID: CA240000039 If continuation sheet 18 of 35 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 06/29/2018 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 beat), chronic obstructive pulmonary disease, and muscle weakness. There was no documented evidence in Resident 85's record a copy of the baseline care plan summary was provided to Resident 85 and/or to her representative. In a concurrent interview with the MDSN, she stated there was no written copy of the baseline care plan summary given to Resident 85, nor to her representative. 9. On June 29, 2018, at 8:17 a.m., Resident 86's record was reviewed with the MDSN. Resident 86 was admitted to the facility on June 13, 2018, with diagnoses which included infection and inflammatory (swelling) reaction due to internal right hip prosthesis (artificial body part), diabetes mellitus, mood disorder, insomnia, hypertension, atherosclerotic heart disease (heart disorder), dysphagia, and right artificial hip joint.. Threre was no documented evidence a copy of the baseline care plan summary was provided to Resident 86 or to his representative. In a concurrent interview with the MDSN, she stated a copy of the baseline care plan summary was not provided to Resident 86 or to the resident'srepresentatives. The facility policy titled, "Comprehensive Person-Centered Care Planning," dated August 2017, was reviewed. The policy indicated, "...The IDT (interdisciplinary) team will also develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7S0J11 Facility ID: CA240000039 If continuation sheet 19 of 35 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 06/29/2018 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 and person-centered care that meet standards of quality care..." The facility policy did not include the provision by the facility of a copy of the base line care plan summary to the resident or to the family representative.

F656 SS=E Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 07/29/2018 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7S0J11 Facility ID: CA240000039 If continuation sheet 20 of 35 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 06/29/2018 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 future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to develop and implement a plan of care (POC) for one resident (Resident 236) who had a nephrostomy tube (tube connected to the kidneys which drains fluids). This failure increased the potential for the residents to not receive the needed care and services. Findings: On June 27, 2018, the record of Resident 236 was reviewed. Resident 236's record indicated she was admitted to the facility on June 19, 2018, with diagnoses which included urinary tract infection and acute pyelonephritis (inflammation of the kidney). On June 26, 2018, at 10:54 a.m., Resident 236 was observed lying in bed and awake. Resident 236 had a nephrostomy tube and nephrostomy bag (a drainage bag). There was no documented evidence a POC was developed for the use of the nephrostomy toube for Resident 236. The record of Resident 236 was reviewed with the the Quality Assurance Nurse (QAN). During FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7S0J11 Facility ID: CA240000039 If continuation sheet 21 of 35 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 06/29/2018 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 a concurrent interview with the QAN, the QAN confirmed the POC was not developed for Resident 236's use of nephrostomy tube. The QAN stated there should have been a POC completed for Resident 236's use of the nephrostomy tube. The facility policy revised August 2017, was reviewed. The policy indicated: "... It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person- centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment..."

F684 SS=D Quality of Care CFR(s): 483.25

F684 07/29/2018 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure nursing care was provided according to nursing standards and physician orders for two of three sampled residents (Residents 12, and 23) when: 1. For Resident 12, the triamcinolone cream (a medicated cream used to treat a variety of skin conditions) was not administered as ordered on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7S0J11 Facility ID: CA240000039 If continuation sheet 22 of 35 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 06/29/2018 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 multiple occasions in the month of June 2018; and 2. For Resident 23, a. The head of the bed (HOB) was not elevated between 30 and 45 degrees while the tube feeding (liquid nutrition administered through a tube in the stomach) was ongoing, according to the physician's order; and b. Metoprolol and Verapamil (blood pressure medications) were administered on multiple occasions when Resident 23's systolic blood pressure (SBP- the top number in the blood pressure measurement reading) was below the parameters ordered by the physician. These failures increased the potential for Resident 12 to experience more discomfort than necessary and for Resident 23 to experience medical complications. Findings: 1. On June 26, 2018, at 1:25 p.m., Resident 12 was observed in his room sitting up in his bed. Resident 12 was observed to have multiple open wounds to his face (under his nose, on his right cheek, on his left eyebrow, and on the area between his eyebrows), and arms (right elbow and hand, and left forearm). The wounds varied in size and appeared to be scratches and were dark reddish in color. During a concurrent interview, Resident 12 stated the staff applied an ointment on the wounds "sometimes." Resident 12 stated his facial wounds hurt. On June 28, 2018, at 8:35 a.m, a concurrent interview and review of Resident 12's record were conducted with the Director of Nursing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7S0J11 Facility ID: CA240000039 If continuation sheet 23 of 35 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 06/29/2018 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 (DON). Resident 12 was admitted to the facility on March 20, 2018, and had diagnoses which included human immunodeficiency virus disease (HIV- an infection which weakens the body's ability to fight infections and diseases) and keratosis pilaris (a skin condition). The physician's order, dated April 14, 2018, indicated, "Triamcinolone...cream...to the face, back, & (and) arms topically every day and evening shift for itching r/t (related to) keratosis pilaris." The treatment record for the month of June 2018, indicated the Triamcinolone cream was not administered on the day shift on June 30, 2018, and on the evening shift on June 8, 9, 12, 13, 14, 16, 17, 18, 19, 20, 21, 22, 24, 25, 26, 27, 28, 29, and 30, 2018 (total of 20 doses). During a concurrent interview, the DON confirmed there was no documented evidence the triamcinalone cream was administered on those shifts. 2a. On June 26, 2018, at 4:36 p.m., Resident 23 was observed with the Quality Assurance Nurse (QAN). Resident 23 was lying in bed, with the HOB almost flat, not elevated between 30 to 45 degrees, while the tube feeding was infusing. During a concurrent interview with the QAN, the QAN stated the HOB should have been elevated between 30 to 45 degrees high when the tube feedings was administered. On June 28, 2018, the record of Resident 23 was reviewed. Resident 23's record indicated she was admitted to the facility on December 24, 2017, with diagnoses which included dysphagia (difficulty swallowing) and hypertension (high blood pressure). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7S0J11 Facility ID: CA240000039 If continuation sheet 24 of 35 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 06/29/2018 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 The physician's order dated January 15, 2018, of "Enteral Feed Order every shift ELEVATE HEAD OF BED 30-45 DEGREES AT ALL TIMES." The facility policy titled, "Tube FeedingNasogastric or Gastrostomy (tube inserted through the nose or into the stomach)," dated June 2007, was reviewed. The policy indicated, "...It is the policy of this facility to assure safe practices in providing tube feedings...Keep the head of the bed elevated 30 degrees at all times..." b. Resident 23's record was reviewed on June 28, 2018. The physician's order, dated January 29, 2018 indicated, "Metoprolol Tartrate 50 mg (milligrams) Give 0.5 tablet via (through) PEG(Percutaneous Endoscopic Gastrostomy Tubetube inserted into the stomach) two times a day for HTN (hypertension) HOLD IF SBP < (below) 130, DPB (diastolic blood pressurebottom number of the blood pressure measurement) <60, HEART RATE <60." The medication administration record (MAR) indicated Metoprolol was not held when Resident 23's SBP was below 130 on multiple occasions, from June 7 through June 26, 2018, as follow: - June 7, 2018: 128/72 at 9 a.m.; - June 9, 2018: 112/80 at 9 a.m., and 128/88 at 5 p.m.; - June 10, 2018: 120/70 at 9 a.m.; - June 13, 2018: 128/80 at 5 p.m.; - June 14, 2018: 124/80 at 9 a.m., and 126/76 at 5 p.m.; - June 15, 2018: 122/70 at 9 a.m.; - June 16, 2018: 116/86 at 5 p.m.; - June 20, 2018: 127/80 at 9 a.m.; - June 21, 2018: 126/74 at 5 p.m.; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7S0J11 Facility ID: CA240000039 If continuation sheet 25 of 35 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 06/29/2018 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 - June 22, 2018: 122/74 at 5 p.m.; - June 24, 2018: 124/80 at 5 p.m.; and - June 26, 2018: 118/74 at 5 p.m. The physician's order, dated January 29, 2018, indicated, "Verapamil HCL (hydrochloride) Tablet 120 MG Give 0.5 tablet via PEG-Tube two times a day for (HTN) HOLD IF SPB <130, DBP <60 HEART RATE <60." The MAR indicated Verapamil was not held when Resident 23's SBP readings were below 130 on multiple occasions, from June 1 through June 27, 2018, as follow: - June 1, 2018: 127/85 at 9 a.m.; - June 2, 2018: 128/87 at 9 a.m.; - June 7, 2018: 126/86 at 9 a.m.; - June 8, 2018: 129/93 at 9 a.m.; - June 9, 2018: 111/81 at 9 a.m.; - June 10, 2018: 124/70 at 9 a.m.; - June 13, 2018: 122/70 at 5 p.m.; - June 14, 2018: 124/60 at 9 a.m., and 124/80 at 5 p.m.; - June 16, 2018: 124/78 at 9 a.m.; - June 21, 2018: 117/60 at 9 a.m.; - June 22, 2018: 122/88 at 9 a.m.; - June 25, 2018: 120/80 at 9 a.m.; - June 26, 2018: 116/72 at 9 a.m.; and - June 27, 2018: 110/75 at 9 a.m., and 128/82 at 5 p.m. The Licensed Vocational Nurse (LVN) 3 was interviewed on June 28, 2018, at 11:20 a.m. LVN 3 stated the medications Metoprolol and Verapamil should have been held and not administered when the SBP were below 130 according to the physician order. The MAR was reviewed with the Director of Nursing (DON) on June 28, 2018, at 11:28 a.m. The DON acknowledged the medications Metoprolol and Verapamil were not held and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7S0J11 Facility ID: CA240000039 If continuation sheet 26 of 35 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 06/29/2018 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 were administered when SBP were below the parameters ordered by the physician. The undated facility policy and procedure titled, "...Med Pass Policy and Procedure," was reviewed. The policy indicated, "...Medications are administered as prescribed...Medications are administered in accordance with written orders of the attending physician..."

F685 SS=D Treatment/Devices to Maintain Hearing/Vision CFR(s): 483.25(a)(1)(2)

F685 07/29/2018 §483.25(a) Vision and hearing To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident§483.25(a)(1) In making appointments, and §483.25(a)(2) By arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure an eye consultation and/or referral was arranged for two of 22 sampled residents (Residents 54 and 28). This failure had the potential for the residents to experience a delay of treatment which may result in the decline of their eyesight. Findings: 1. On June 27, 2018, at 10:39 a.m., Resident 54 was interviewed. He stated he wanted to have eyeglasses but the facility did not offer a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7S0J11 Facility ID: CA240000039 If continuation sheet 27 of 35 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 06/29/2018 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 consultation with an eye doctor. Resident 54 stated when he asked to see an eye doctor, he was told the facility did not have one. The record of Resident 54 was reviewed on June 27, 2018. Resident 54's record indicated he was admitted to the facility on May 15, 2018, with diagnoses which included type two diabetes mellitus (high blood sugar). There was no documentation in Resident 54's record the facility arranged a vision consultation or was evaluated by an eye doctor. On June 29, 2018, at 2:17 p.m., Resident 54's record was reviewed with the Social Worker (SW). During a concurrent interview with the SW, he stated Resident 54 was on the list of the residents to be seen by the eye doctor for the month of May 2018. The SW stated Resident 54 was not seen by the eye doctor. The SW further stated he should have followed up with the eye doctor regarding Resident 54's consultation. 2. On June 27, 2018, at 9:51 a.m., Resident 28 was observed sitting in his wheelchair beside his bed, alert, and not wearing eyeglasses. During a concurrent interview, Resident 28 stated she had poor vision and she had notified the facility staff, but she had been not seen by the eye doctor. Resident 28 stated she only had one good eye which was hard for her. The record of Resident 28 was reviewed on June 29, 2018. Resident 28 was admitted to the facility on April 17, 2018, with diagnoses which included type two diabetes mellitus (high blood sugar). The summarized physician orders indicated an order on April 17, 2018, for "Eye-Health and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7S0J11 Facility ID: CA240000039 If continuation sheet 28 of 35 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 06/29/2018 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 Vision Consult with Follow-Up Treatment as indicated." There was no documented evidence Resident 28 was seen by the eye doctor. Resident 28's record was reviewed with the SW on June 29, 2018, at 8:29 a.m. In a concurrent interview with the SW, he confirmed Resident 28 was not seen by the eye doctor. The SW stated he should have called the eye doctor regarding Resident 28's eye consultation. The facility policy titled, "Physicians, Consulting," revised November 2007, was reviewed. The policy indicated "...Purpose To promote continuity of care..." The facility policy did not address the facility procedure for the residents who needed vision and eye consultation.

F761 SS=E Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 07/29/2018 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7S0J11 Facility ID: CA240000039 If continuation sheet 29 of 35 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 06/29/2018 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 §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the items and medications stored were not expired when: 1. Four bottles of expired blood glucose test strips (used to determine blood sugar) and one box of expired blood collection needles were in the medication storage room available for use. This failure may result in inaccurate blood sugar determination results; 2a. Two opened and undated insulin pens (high blood sugar medication) were observed in the medication cart available for use; and b. One expired bottle of melatonin (medication used for sleep) was observed in the medication cart available for use. These failures increased the potential for residents to receive ineffective medications. Findings: 1. On June 28, 2018, at 9:42 a.m., the inspection of the medication storage room was conducted with the Director of Nursing (DON). Four bottles of blood glucose test strips, with an expiration date of July 2017, were observed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7S0J11 Facility ID: CA240000039 If continuation sheet 30 of 35 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 06/29/2018 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 on the medication storage shelf (expired for almost one year). On June 28, 2018, at 10:36 a.m., one box of 22 G (gauge) x 1 inch blood collection needles, with an expiration date of June 2017, was observed on the medication storage shelf (expired for one year). During a concurrent interview with the DON, the DON stated there should not be expired medications and/or items in the medication storage room. On June 29, 2018, at 7:56 a.m., the Director of Staff Development (DSD) was interviewed. The DSD confirmed there was an error in not removing the expired blood glucose test strips from the medication storage room. The DSD stated the expired blood glucose test strips and expired blood collection needles should not be in the medication storage room. 2a. On June 28, 2018, at 10:15 a.m., the inspection of Wing A medication cart was conducted with Licensed Vocational Nurse (LVN) 1. The two insulin pens labeled, "Lantus solostar (an insulin medication)100 units/ (per) ml (milliliter) (U (unit)-100)," were observed opened, not dated, and available for use in the medication cart. One of the insulin pens was observed with 180 units remaining. The other insulin pen was observed with 220 remaining. During a concurrent interview with LVN 1, LVN 1 confirmed the amount remaining in both insulin pens. LVN 1 stated each insulin pen contained 300 units of insulin when they were unopened. LVN 1 stated the insulin pens should have been dated when they were opened. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7S0J11 Facility ID: CA240000039 If continuation sheet 31 of 35 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 06/29/2018 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 On June 29, 2018, Resident 71's record was reviewed. Resident 71 was admitted to the facility on June 2, 2018, with diagnoses which included diabetes mellitus (high blood sugar). On June 29, 2018, at 3:30 p.m., the DON was interviewed, the DON stated the insulin pens should have been dated after they were opened. According to Lexicomp Online, "...Insulin Glargine (generic name of Lantus)...Once in use, store prefilled pens...and use within 28 days..." The facility's policy titled,"Medication Storage," revised November 2007, was reviewed. The policy indicated, "...Policy...Insulin that is currently in use (always date and initial when opened)..." b. On June 28, 2018, at 11:36 a.m., the medication cart at the Wing B was inspected with LVN 1. One bottle of "Melatonin 5 milligrams (mg)", with an expiration date of January 31, 2017 (one year and almost five months expired), was observed inside the medication cart ready for use. During a concurrent interview with LVN 1, she confirmed the bottle of melatonin expired on January 31, 2017. LVN 1 further stated the melatonin should have been removed from the cart when expired. On June 29, 2018, at 7:50 a.m., the DON stated there should be no expired medication in the cart. The DON further stated the expired medication should have been removed from the cart when expired. The undated facility policy and procedure titled, "Medication Storage In The Facility," was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7S0J11 Facility ID: CA240000039 If continuation sheet 32 of 35 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 06/29/2018 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 reviewed. The policy indicated, "...Medications and biologicals are stored safely...and properly, following manufacturer's recommendations or those of the supplier...Outdated...medications...are immediately removed from stock, disposed of according to procedures for medication disposal..."

F926 SS=E Smoking Policies CFR(s): 483.90(i)(5)

F926 07/29/2018 §483.90(i)(5) Establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also take into account nonsmoking residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure policies were established and implemented regarding smoking safety for three of 22 sampled residents (Residents 8, 35, and 47) when Residents 8, 35, and 47 were allowed to keep their cigarettes and/or lighter in their possession. These failures resulted in the facility not implementing their Smoking policy. Findings: 1. On June 26, 2018, at 4:59 p.m., Resident 8 was interviewed. Resident 8 stated he goes out for smoke breaks a few times a day. Resident 8 stated, "I keep my cigarettes at the nursing station, but keep my lighter in my luggage." On June 27, 2018, at 3:58 p.m., Resident 8's record was reviewed. Resident 8's undated care plan indicated, "...has potential for injury FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7S0J11 Facility ID: CA240000039 If continuation sheet 33 of 35 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 06/29/2018 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 r/t (related to) Smoking prefers to keep lighter and cigarette in his possession despite of explanation of risks; smokes as desired outside the designated smoking schedule..." On June 28, 2018, at 3:25 p.m., Resident 8 was observed pulling his own cigarette and lighter from his canvas luggage bag located around his shoulders. On June 28, 2018, at 3:29 p.m., the Concierge (a staff member of the facility who assists residents) was interviewed. The Concierge stated, "I bring the carton of cigarettes to the nurse's station, and the resident's lighter is supposed to be kept at the nurse's station. The residents who are functionally able to, can keep their cigarettes and lighters with them." 2. On June 26, 2018, at 4:32 p.m., Resident 35 was interviewed and stated his two cigarette lighters were kept in the top drawer of his bedside table. Resident 35 showed the contents of the top drawer of his bedside table where two cigarette lighters were observed. On June 27, 2018, at 4:08 p.m., Resident 35's record was reviewed. Resident 35's undated care plan indicated, "...has potential for injury r/t Smoking, prefers not to wear apron and prefers to keep lighter with him; smokes as desired outside the designated smoking schedule..." 3. On June 27, 2018, at 3:12 p.m., an observation was conducted with the Activities Director (AD). Resident 47 was observed sitting out by the designated smoking area. During a concurrent interview with the Activities Director (AD), the AD stated, "The resident has his own cigarettes and lighter." On June 27, 2018, at 3:55 p.m., Resident 47's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7S0J11 Facility ID: CA240000039 If continuation sheet 34 of 35 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 06/29/2018 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 record was reviewed. Resident 47's undated care plan indicated, "...has potential for injury r/t Smoking, Refusal to follow schedule smoking time, refusal to wear apron, and prefers to keep lighter and cigarette in his possession despite of explanation of risks..." On June 28, 2018, at 2:21 p.m., Certified Nursing Assistant (CNA) 1 was interviewed. CNA 1 stated, "If a resident is alert and oriented, the resident could keep their cigarettes." On June 28, 2018, at 2:32 p.m., the DON was interviewed. The DON stated, "If the resident insists on keeping their own cigarettes and lighter, then we put it on the resident's care plan." The facility policy and procedure titled, "Smoking Policy," revised November 2017, was reviewed. The policy indicated, "...It is also policy to provide those residents who choose to smoke a means in which to do so that does not jeopardize their safety or the safety of others residing in the facility... no lighting materials (e.g. matches, lighters), or smoking devices will be allowed to be kept in the possession of the residents, either on their person or in the facility...If it is determined that a resident is a safe smoker, smoking materials will still be retained by nursing staff and they may come an [sic] request the smoking materials at the time they desire, to go out to smoke unsupervised..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7S0J11 Facility ID: CA240000039 If continuation sheet 35 of 35