Other·October 4, 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 one facility reported incident. Facility reported incident number: CA00593933 Representing the California Department of Public Health: Surveyor 36779, HFEN The inspection was limited to the specific facility reported incident investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for facility reported incident number CA00593933.

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

F609 09/14/2018 §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 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: LECD11 Facility ID: CA240000039 If continuation sheet 1 of 5 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 08/24/2018 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 protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §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 observation, interview, and record review, the facility failed to report an allegation of verbal abuse to the California Department of Public Health (CDPH) for one resident (Resident 1), within two hours of becoming aware of the alleged abuse. This failure had the potential to place Resident 1, and other residents in the facility, at risk of harm from abuse. Findings: On July 17, 2018, at 10:48 a.m., an unannounced visit was made to the facility to investigate an allegation of verbal abuse made by Resident 1. On July 17, 2018, at 11:05 a.m., an interview was conducted with the Operations Manager (OM). The OM stated on May 25, 2018, at 5:30 p.m., Resident 1 alleged Resident 2 was verbally abusive to him. The OM confirmed he reported the allegation to CDPH on July 5, 2018, at 10:26 a.m. (There were 41 days between the alleged verbal abuse of Resident 1 and the report made to CDPH). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LECD11 Facility ID: CA240000039 If continuation sheet 2 of 5 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 08/24/2018 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 OM stated he did not report the allegation to CDPH within 2 hours of being aware of the allegation. The OM stated he should have reported the allegation to CDPH within 2 hours of being aware of the allegation. The OM stated on May 25, 2018, at 5:30 p.m., Resident 1 alleged Resident 2 told 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." On July 17, 2018, at 3:10 p.m., Resident 1 was observed in the patio area, sitting in a wheelchair. Resident 3 was sitting in a wheelchair nearby. A concurrent interview was conducted with Resident 1 and Resident 3. Resident 1 stated there was an incident in May 2018, in which Resident 2 blocked him from exiting his room. Resident 1 stated he notified the OM of the incident. Resident 1 stated about a week later, he was sitting at the patio table and Resident 2 walked up to him and said, "You know what happens to people who snitch where I come from? They get stabbed." Resident 1 stated the OM had just walked out onto the patio area and was nearby and heard what Resident 2 said to him. Resident 3 stated she was sitting at the patio table that day and witnessed the incident. Resident 3 stated she heard Resident 2 make the statement to Resident 1 about being stabbed. Resident 1 stated, "I didn't sleep well for about a week." Resident 1 stated, "I felt like I had to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LECD11 Facility ID: CA240000039 If continuation sheet 3 of 5 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 08/24/2018 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 look over my shoulder." On July 17, 2018, Resident 1's record was reviewed. Resident 1 was admitted to the facility on March 15, 2018, with diagnoses including sepsis (infection in the blood), diabetes (high blood sugar), cellulitis (inflammation of skin), abscess (swelling with pus) in the left ankle and foot, osteomyelitis (bone infection), and a right leg below the knee amputation (surgical removal of lower leg below the knee). Resident 1's Minimum Data Set (MDS - an assessment tool), dated March 24, 2018, indicated his Brief Interview for Mental Status (BIMS) was 15 (on a scale of 0-15 in which 1315 indicates the patient was cognitively intact). On July 17, 2018, Resident 2's record was reviewed. Resident 2 was admitted to the facility on February 3, 2018, with diagnoses including traumatic subdural hemorrhage (bleeding in the brain as a result of an injury), alcohol dependence (alcoholism), and anxiety disorder (mood disorder). Resident 2's MDS, dated May 15, 2018, indicated his BIMS was 14. The care plan dated March 5, 2018, indicated, "...potential to demonstrate verbally abusive behaviors r/t (related to) Poor impulse control, anxiety secondary to alcohol withdrawal aeb (as evidenced by) angry outburst...Resident has (sic) verbal altercation with another resident..." The care plan indicated Resident 2 had a history of verbal abuse towards other residents two months prior to the incident towards Resident 1 on May 25, 2018. On July 19, 2018, a review of documents from Resident 3's record was conducted. Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LECD11 Facility ID: CA240000039 If continuation sheet 4 of 5 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 08/24/2018 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 3 was admitted to the facility on June 24, 2017. Resident 3's MDS dated April 5, 2018, indicated her BIMS was 14. On July 24, 2018, at 10:30 a.m., an interview was conducted with the Social Services Director (SSD). The SSD confirmed Resident 1 alleged Resident 2 was verbally abusive to him while they were at the patio table on May 25, 2018. On July 24, 2018, at 4:48 p.m., an interview was conducted with the Registered Nurse Supervisor (RNS). The RNS confirmed Resident 1 alleged Resident 2 was verbally abusive to him while they were at the patio table on May 25, 2018. The "CONFIDENTIAL REPORT...OF SUSPECTED DEPENDENT ADULT/ELDER ABUSE," dated July 5, 2018, was reviewed. The report indicated there was a "verbal argument" between Resident 1 and Resident 2, on May 25, 2018. The report indicated it was transmitted by fax to CDPH on July 5, 2018, at 12:07 p.m. (There were 41 days between the alleged verbal abuse of Resident 1 and the report made to CDPH). The facility policy and procedure titled, "Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment," dated November 28, 2017, was reviewed. The policy indicated, "...In response to allegations of abuse...the Facility will...Ensure that all alleged violations involving abuse...are reported immediately but...Not later than two (2) hours after the allegation is made if the events that cause the allegation involve abuse...Ensure that all alleged violations involving abuse...are reported to...The State Survey Agency..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LECD11 Facility ID: CA240000039 If continuation sheet 5 of 5