Other·November 14, 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: CA00592559 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 CA00592559.

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

F609 10/01/2018 §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: TK3G11 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 09/13/2018 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 for harm from abuse. Findings: On June 28, 2018, at 4:35 p.m., an unannounced visit was made to the facility to investigate an allegation of physical abuse to Resident 1. On June 29, 2018, at 8:50 a.m., Resident 1 was observed in her room in a Geri chair (an upholstered recliner on wheels), awake and alert. An interview was attempted, but Resident 1 did not respond to any communication. On June 29, 2018, at 8:55 a.m., Resident 2 was observed in her room, in bed. Two staff FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TK3G11 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 09/13/2018 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 members were sitting beside her bed. Resident 2 was observed trying to get out of bed and was speaking in a confused manner. An interview was attempted with Resident 2, but she continued speaking in a confused manner and there was no indication she understood what was asked. On August 14, 2018, at 3:35 p.m., an interview was conducted with the Operations Manager (OM) regarding the incident between Resident 1 and Resident 2 on June 23, 2018. The OM stated the incident occurred on "June twentythird (2018)...at 12:30 p.m." The OM stated he reported the incident on "June twenty-fifth (2018) at 2031 (8:31 p.m.)." The OM confirmed he did not report the incident within two hours. When asked if he should have reported the incident within two hours, the OM stated, "Yes." On September 6, 2018, at 11:38 a.m., an interview was conducted with Registered Nurse (RN) 1. RN 1 stated she witnessed the incident between Resident 1 and Resident 2 on June 23, 2018. RN 1 stated Resident 1 was sitting in her Geri chair (an upholstered recliner on wheels) at the nurses station and she observed Resident 2 grabbing Resident 1's arm (with two hands) and moved Resident 1's arm around in a shaking motion which lasted one to two seconds. On August 1, 2018, a review of Resident 1's record was conducted. Resident 1's record indicated she was admitted to the facility on October 5, 2017, with diagnoses including cognitive communication deficit (a decline in the ability to communicate due to mental impairment), dementia (memory loss), and anxiety (mood disorder). Resident 1's Minimum Data Set (MDS - an assessment tool) dated April 27, 2018, indicated her Brief FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TK3G11 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 09/13/2018 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 Interview for Mental Status (BIMS) was zero (on a scale of 0-15, in which 0-7 indicated the person was severely impaired). The "Progress Note," dated June 26, 2018, at 9:30 a.m., indicated, "...on 6/23/2018 This (sic) patient was sitting at nurses station when (Resident 2) came up to this patient and took her arm and shook it..." On August 2, 2018, a review of Resident 2's record was conducted. Resident 2 was admitted to the facility on March 29, 2014, with diagnoses including psychosis (a mental disorder), bipolar disorder (a mental disorder), Alzheimer's (memory loss), and anxiety disorder. The "Progress Note," dated June 23, 2018, at 3:17 p.m., indicated, "At 1230 (12:30 p.m.), this patient was found to have grabbed another resdients (sic) arm at the nurses station and shook arm (sic)..." The document titled, "CONFIDENTIAL REPORT...OF SUSPECTED DEPENDENT ADULT/ELDER ABUSE," dated June 25, 2018, was reviewed. The report indicated, "(Resident 1) was sitting at nurses station and (Resident 2) grabbed her on the arm and shook her arm..." The report indicated the incident occurred on June 23, 2018, at 12:30 p.m. The report indicated it was transmitted by fax to CDPH on June 25, 2018, at 8:37 p.m. (56 hours after the incident). The facility policy and procedure titled, "Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment," revised November 28, 2017, was reviewed. The policy indicated, "...the Facility will...Ensure that all alleged violations involving abuse...or mistreatment...are reported immediately FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TK3G11 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 09/13/2018 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 but...Not later than two (2) hours after the allegation is made..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TK3G11 Facility ID: CA240000039 If continuation sheet 5 of 5