Other·June 20, 2017

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 for the California Department of Public Health during an abbreviated standard survey for the investigation of one entity reported incident. Complaint number: CA00479002 Representing the California Department of Public Health: Surveyor 33235, HFEN The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency deficiency was issued for entity reported incident CA00479002.

F224 SS=D PROHIBIT

F224 MISTREATMENT/NEGLECT/MISAPPROPRIA TN CFR(s): 483.13(c) 06/09/2017 The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. This REQUIREMENT is not met as evidenced by: Based on interview and record review the 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: V7YE11 Facility ID: CA240000061 If continuation sheet 1 of 4 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555084 (X3) DATE SURVEY COMPLETED 05/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DESERT SPRINGS HEALTHCARE & WELLNESS CENTRE 82262 Valencia Ave Indio, CA 92201 (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 facility was negligent in protecting one resident (Resident 1) by allowing unmonitored access to Resident 1 by a family member (FM 1)who was to have only supervised visits. This failed practice resulted in the abduction of Resident 1 from the facility. Findings: On March 9, 2016, an unannounced visit was made to investigate an entity reported incident regarding the abduction of Resident A. On March 9, 2016, the medical record for Resident A was reviewed. Resident A was admitted to the facility on July 8, 2015, with diagnoses including COPD (Chronic Obstructive Pulmonary Disease- a condition causing shortness of breath) and dementia (loss of mental function which makes a person incapable of making their own decisions). Resident 1 was placed under conservatorship (a person appointed by the court to ensure a resident's rights are protected) on September 9, 2015. A Conservatorship Report dated October 20, 2015, indicated Adult Protective Services investigated seven allegations of abuse toward Resident A by FM 1. All of the allegations were for neglect; three of the allegations were substantiated. The Conservatorship Report indicated Resident 1, "Requires 24-hour care and was unable to make decisions regarding her needs for physical health, food, clothing, or shelter and is unable to resist fraud or undue influence." Initially, FM 1 was barred from visiting Resident 1 because FM 1 made numerous statements she would remove Resident 1 from the facility and attempted to interfere with the patient's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V7YE11 Facility ID: CA240000061 If continuation sheet 2 of 4 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555084 (X3) DATE SURVEY COMPLETED 05/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DESERT SPRINGS HEALTHCARE & WELLNESS CENTRE 82262 Valencia Ave Indio, CA 92201 (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 care during visits. Interdisciplinary Team Conference notes, dated December 5, 2015, indicated the conservator, who was in attendance at the meeting, stated FM 1 could start supervised visits with Resident 1. During an interview conducted with Certified Nursing Assist (CNA) 1 on March 16, 2016, at 11:45 a.m., she stated that, on Sunday, March 6, 2016, FM 1 came to the facility along with an unidentified male. CNA 1 stated that she believed FM 1 entered through the unlocked front door some time before 8:30 a.m., but no one saw her enter the building. CNA 1 stated FM 1 asked her for a blanket and assistance to get portable oxygen for Resident A. CNA 1 stated she did not know FM 1's identity, but she complied with FM 1's request. CNA 1 stated she was told the previous year that FM 1 could only have supervised visits with Resident A, but she did not know who FM 1 was and never received any instruction on how to conduct a supervised visit. During an interview conducted with the facility Receptionist (Staff) 1 on March 14, 2016, at 3 p.m., she stated, on March 6, 2016, FM 1 told her that she was taking Resident A to the patio. Staff 1 stated she saw FM 1 pushing Resident A's wheelchair down the hall. FM 1 asked Staff 1 for a cup of coffee for Resident A. When Staff 1 returned with the coffee, FM 1 asked for Thickener (substance used to thicken liquids for individuals who are prone to choke on liquids) for the coffee. Staff 1 stated when she returned with the thickened coffee, Resident 1, FM 1, and the unidentified male were gone. Staff 1 stated she reported Resident 1 was missing to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V7YE11 Facility ID: CA240000061 If continuation sheet 3 of 4 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555084 (X3) DATE SURVEY COMPLETED 05/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DESERT SPRINGS HEALTHCARE & WELLNESS CENTRE 82262 Valencia Ave Indio, CA 92201 (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 registered nurse and facility staff found the empty wheelchair and Resident A's discarded name band in the parking lot. Staff 1 stated she remembered being told that FM 1 could only have supervised visits with Resident A. Staff 1 stated she did not know the identity of FM 1 when she asked for assistance for Resident 1. Staff 1 stated she did not question FM 1 as to her identity and did not keep Resident 1 in view when FM 1 was with Resident 1. A facility policy and procedure titled, "Temporary Limitation of Visitation Rights," dated January 1, 2012, was reviewed. The policy and procedure did not include staff guidelines for supervised visits. On March 16, 2016 at 11:40 a.m., a phone interview with the Director of Staff Development (DSD) was conducted. The DSD stated Resident 1 had not been found. The facility failed to ensure FM 1 was supervised during visits to Resident A. This failure allowed FM 1 the opportunity to abduct Resident 1 from the facility during an unsupervised visit. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V7YE11 Facility ID: CA240000061 If continuation sheet 4 of 4