Other·August 29, 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 two linked complaints. Complaint number: CA00536151 and CA00536081 Representing the California Department of Public Health: Surveyor 33235, HFEN The inspection was limited to the specific complaints investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for complaint number CA00536151 and CA00536081.

F159 SS=D FACILITY MANAGEMENT OF PERSONAL FUNDS CFR(s): 483.10(f)(10)(i)-(iv)

F159 09/01/2017 (f)(10)(i) …If a resident chooses to deposit personal funds with the facility, upon written authorization of a resident, the facility must act as a fiduciary of the resident's funds and hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility, as specified in this section. (f)(10)(ii) Deposit of Funds. (A) In general: Except as set out in paragraph (f)(l0)(ii)(B) of this section, the facility must deposit any residents' personal funds in excess of $100 in an interest bearing account (or accounts) that is separate from any of the facility's operating accounts, and that credits all 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: JRGJ11 Facility ID: CA240000092 If continuation sheet 1 of 13 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: _______________ 056229 (X3) DATE SURVEY COMPLETED 08/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALM SPRINGS HEALTHCARE & REHABILITATION CENTER 277 S Sunrise Way Palm Springs, CA 92262 (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 interest earned on resident's funds to that account. (In pooled accounts, there must be a separate accounting for each resident's share.) The facility must maintain a resident's personal funds that do not exceed $100 in a non-interest bearing account, interest-bearing account, or petty cash fund. (B) Residents whose care is funded by Medicaid: The facility must deposit the residents' personal funds in excess of $50 in an interest bearing account (or accounts) that is separate from any of the facility's operating accounts, and that credits all interest earned on resident's funds to that account. (In pooled accounts, there must be a separate accounting for each resident's share.) The facility must maintain personal funds that do not exceed $50 in a noninterest bearing account, interestbearing account, or petty cash fund. (f)(10)(iii) Accounting and records. (A) The facility must establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident’s personal funds entrusted to the facility on the resident’s behalf. (B) The system must preclude any commingling of resident funds with facility funds or with the funds of any person other than another resident. (C)The individual financial record must be available to the resident through quarterly statements and upon request. (f)(10)(iv) Notice of certain balances. The facility must notify each resident that receives Medicaid benefits(A) When the amount in the resident’s account reaches $200 less than the SSI resource limit FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JRGJ11 Facility ID: CA240000092 If continuation sheet 2 of 13 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: _______________ 056229 (X3) DATE SURVEY COMPLETED 08/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALM SPRINGS HEALTHCARE & REHABILITATION CENTER 277 S Sunrise Way Palm Springs, CA 92262 (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 for one person, specified in section 1611(a)(3) (B) of the Act; and (B) That, if the amount in the account, in addition to the value of the resident’s other nonexempt resources, reaches the SSI resource limit for one person, the resident may lose eligibility for Medicaid or SSI. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to deposit one resident's (Resident 1) funds into an interest bearing account and failed to monitor the total amount of funds in Resident 1's account. This failure caused Resident 1 to lose potential interest on the funds and also to become ineligible for Medi-cal payment for medical care. Findings: On May 22, 2017, a visit was made to the facility to investigate two linked complaints. On May 22, 2017, the medical record for Resident 1 was reviewed. Resident 1 was admitted to the facility on February 28, 2014 with diagnoses including dementia (confusion, memory loss) and Chronic Obstructive Pulmonary Disease (disease causing shortness of breath). On May 22, 2017, at 10:50 am, an interview was conducted with Administrator 1 (ADM 1). ADM 1 stated $13,000 of Resident 1's funds was found in a corporate account. ADM 1 stated the money was placed in the corporate account before she took over as administrator at the facility. ADM 1 stated she had no idea FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JRGJ11 Facility ID: CA240000092 If continuation sheet 3 of 13 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: _______________ 056229 (X3) DATE SURVEY COMPLETED 08/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALM SPRINGS HEALTHCARE & REHABILITATION CENTER 277 S Sunrise Way Palm Springs, CA 92262 (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 why corporate was getting the funds, when it started, or how the funds were maintained for the resident. ADM 1 stated a check for the funds had been given to the new facility where Resident 1 now lived. On May 22, 2017, at 11:15 am, an interview was conducted with Social Worker 1 (SW 1). SW 1 stated Resident 1 had a trust fund at the facility with a little under $1000. SW 1 stated the funds were used to buy toiletries, clothes, or any other personal items the resident wanted. SW 1 stated she did not know anything about Resident 1 having any additional funds. On May 22, 2017, at 11:45 am, a phone interview was conducted with Director of Patient Care Advocacy (DPCA). DPCA stated he had gotten a call from Social Worker 2 (SW 2) (at the facility where Resident 1 had been transferred), regarding money being held for Resident 1. DPCA stated he found $13,000 was held in a corporate account for Resident 1. DPCA stated the corporate office was the payee for Resident 1's Social Security payments. DPCA stated he called the corporate compliance office and asked for a check to be issued to Resident 1 and sent to her new residence. DPCA stated he was not familiar with the corporate policy for handling resident funds. On May 30, 2017, at 8:45 am, a phone interview was conducted with supervisor at the Central Business Office (CBO) for the corporation. CBO stated a resident's Social Security income should be received by the facility to pay their share of cost for their care and any remainder would be placed in a trust fund for the resident. CBO stated Resident 1's, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JRGJ11 Facility ID: CA240000092 If continuation sheet 4 of 13 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: _______________ 056229 (X3) DATE SURVEY COMPLETED 08/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALM SPRINGS HEALTHCARE & REHABILITATION CENTER 277 S Sunrise Way Palm Springs, CA 92262 (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 Social Security payments were sent to the facility, but automatically placed in a corporate account. CBO stated the funds were always under Resident 1's name in the corporate account. CBO initially stated this practice began in January 2015, but later amended the start date to October 2014. CBO stated the funds were mailed to Resident 1's new facility on May 18, 2017. CBO stated it would be the administrator at the facility who would be responsible to review the account's details and ask for any changes or corrections. On May 30, 2017, documentation of Resident 1's corporate account was reviewed. The documentation indicated funds for Resident 1 were deposited into a corporate account every month beginning in October 2014. Share of cost deduction for medical care did not begin until January 2016. On May 31, 2016 at 9:05 am, a phone interview was conducted with the Medical Records Supervisor (MRS). MRS stated she tracked each of the resident's trust funds. MRS stated a resident's Social Security would come to the facility, but would be automatically transferred to the Central Business Office. MRS stated the only funds placed in the trust fund at the facility for each resident was $35 each month. Those funds were used to buy personal items or food not prepared at the facility that the resident wanted. MRS stated the social worker had a petty cash fund from which she would give a resident the amount of money needed for a purchase. At the end of the month, money from the resident's account would repay the amount taken from the petty cash fund. MRS stated she did not receive the corporate spreadsheets for the resident accounts and would not know how to read the corporate account FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JRGJ11 Facility ID: CA240000092 If continuation sheet 5 of 13 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: _______________ 056229 (X3) DATE SURVEY COMPLETED 08/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALM SPRINGS HEALTHCARE & REHABILITATION CENTER 277 S Sunrise Way Palm Springs, CA 92262 (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 spreadsheets. MRS stated she thought Resident 1 received $686 in Social Security payment every month. MRS stated she would only see the $35 deposited into Resident 1's trust fund for incidental purchases. On May 31, 2017, at 9:35 am, a phone interview was conducted with CBO. CBO was asked to explain the notations made on Resident 1's spreadsheet of her corporate account. CBO stated "cash receipt" or "cash receipt-RFMS" would indicate Social Security payments to Resident 1. CBO stated the funds are posted to any month, there are no rules. As an example, CBO stated funds that came in March 2016 could be posted to January 2015. The notation, "Room Charge" was the notation used to indicate a share of cost. CBO stated funds held for a resident in the corporate account would not receive any interest. CBO stated Resident 1 did not receive any interest on the $13,000 held in the corporate account. CBO stated the Administrator at the facility would receive a monthly statement of the funds in the resident's corporate account. On May 31, 2017, at 10:35 am, a phone interview was conducted with ADM 1. ADM 1 stated as administrator she does receive monthly statements for each residents funds held in a corporate account. ADM 1 stated she was not aware of any resident receiving interest on their funds. ADM 1 stated, "That's the way it has always been done." On June 20, 2017, at 11:35 am, an interview was attempted with Resident 1 with the assistance of Health Facilities Evaluator Nurse (HEFN 1) as Spanish interpreter. Resident 1 was able to state her name, time of day, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JRGJ11 Facility ID: CA240000092 If continuation sheet 6 of 13 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: _______________ 056229 (X3) DATE SURVEY COMPLETED 08/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALM SPRINGS HEALTHCARE & REHABILITATION CENTER 277 S Sunrise Way Palm Springs, CA 92262 (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 name of facility she is currently living. Resident 1 stated she remembered the previous facility. Resident 1 stated she had problems with her money at at the previous facility every month. Resident 1 stated she did not want to talk about the money or anything else. On June 20, 2017, at 11:45 am, an interview was conducted with Administrator 2 (ADM 2) of the facility where Resident 1 currently resides. ADM 2 stated Resident 1 would lose her MediCal funding for health care as a result of the funds that were being placed in her trust fund at this facility. ADM 2 stated this may result in Resident 1 needing to pay privately for her care. On June 22, 2017, the facility policy and procedure (P&P) dated November 15, 2001, and titled, "Resident Trust Accounts" was reviewed. The P&P indicated, "The resident trust fund is managed by the facility and is kept in an interest bearing account..." The P&P also indicated, "1. When the Resident's account approaches the state limit (a balance within $200 under the limit), the facility's Social services Department or designee must notify the resident and/or responsible part. 2. In the case of excess resources, appropriate actions must be taken as necessary according to specific state regulations."

F224 SS=D PROHIBIT

F224 MISTREATMENT/NEGLECT/MISAPPROPRIA TN FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JRGJ11 09/01/2017 Facility ID: CA240000092 If continuation sheet 7 of 13 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: _______________ 056229 (X3) DATE SURVEY COMPLETED 08/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALM SPRINGS HEALTHCARE & REHABILITATION CENTER 277 S Sunrise Way Palm Springs, CA 92262 (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 CFR(s): 483.12(b)(1)-(3) §483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident’s symptoms. 483.12(b) The facility must develop and implement written policies and procedures that: (b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (b)(2) Establish policies and procedures to investigate any such allegations, and (b)(3) Include training as required at paragraph §483.95, This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to deposit one resident's (Resident 1) funds into an interest bearing account and failed to monitor the total amount of funds in Resident 1's account. This failure caused Resident 1 to lose potential interest on the funds and also to become ineligible for Medi-cal payment for medical care. Findings: On May 22, 2017, a visit was made to the facility to investigate two linked complaints. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JRGJ11 Facility ID: CA240000092 If continuation sheet 8 of 13 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: _______________ 056229 (X3) DATE SURVEY COMPLETED 08/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALM SPRINGS HEALTHCARE & REHABILITATION CENTER 277 S Sunrise Way Palm Springs, CA 92262 (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 May 22, 2017, the medical record for Resident 1 was reviewed. Resident 1 was admitted to the facility on February 28, 2014 with diagnoses including dementia (confusion, memory loss) and Chronic Obstructive Pulmonary Disease (disease causing shortness of breath). On May 22, 2017, at 10:50 am, an interview was conducted with Administrator 1 (ADM 1). ADM 1 stated $13,000 of Resident 1's funds was found in a corporate account. ADM 1 stated the money was placed in the corporate account before she took over as administrator at the facility. ADM 1 stated she had no idea why corporate was getting the funds, when it started, or how the funds were maintained for the resident. ADM 1 stated a check for the funds had been given to the new facility where Resident 1 now lived. On May 22, 2017, at 11:15 am, an interview was conducted with Social Worker 1 (SW 1). SW 1 stated Resident 1 had a trust fund at the facility with a little under $1000. SW 1 stated the funds were used to buy toiletries, clothes, or any other personal items the resident wanted. SW 1 stated she did not know anything about Resident 1 having any additional funds. On May 22, 2017, at 11:45 am, a phone interview was conducted with Director of Patient Care Advocacy (DPCA). DPCA stated he had gotten a call from Social Worker 2 (SW 2) at the facility where Resident 1 had been transferred, regarding money being held for Resident 1. DPCA stated he found $13,000 was held in a corporate account for Resident 1. DPCA stated the corporate office was the payee for Resident 1's Social Security FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JRGJ11 Facility ID: CA240000092 If continuation sheet 9 of 13 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: _______________ 056229 (X3) DATE SURVEY COMPLETED 08/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALM SPRINGS HEALTHCARE & REHABILITATION CENTER 277 S Sunrise Way Palm Springs, CA 92262 (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 payments. DPCA stated he called the corporate compliance office and asked for a check to be issued to Resident 1 and sent to her new residence. DPCA stated he was not familiar with the corporate policy for handling resident funds. On May 30, 2017, at 8:45 am, a phone interview was conducted with supervisor at the Central Business Office (CBO) for the corporation. CBO stated a resident's Social Security income should be received by the facility to pay their share of cost for their care and any remainder would be placed in a trust fund for the resident. CBO stated Resident 1's, Social Security payments were sent to the facility, but automatically placed in a corporate account. CBO stated the funds were always under Resident 1's name in the corporate account. CBO initially stated this practice began in January 2015, but later amended the start date to October 2014. CBO stated the funds were mailed to Resident 1's new facility on May 18, 2017. CBO stated it would be the administrator at the facility who would be responsible to review the account's details and ask for any changes or corrections. On May 30, 2017, documentation of Resident 1's corporate account was reviewed. The documentation indicated funds for Resident 1 were deposited into a corporate account every month beginning in October 2014. Share of cost deduction for medical care did not begin until January 2016. On May 31, 2016 at 9:05 am, a phone interview was conducted with the Medical Records Supervisor (MRS). MRS stated she tracked each of the resident's trust funds. MRS stated a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JRGJ11 Facility ID: CA240000092 If continuation sheet 10 of 13 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: _______________ 056229 (X3) DATE SURVEY COMPLETED 08/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALM SPRINGS HEALTHCARE & REHABILITATION CENTER 277 S Sunrise Way Palm Springs, CA 92262 (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's Social Security would come to the facility, but would be automatically transferred to the Central Business Office. MRS stated the only funds placed in the trust fund at the facility for each resident was $35 each month. Those funds were used to buy personal items or food not prepared in the facility that the resident wanted. MRS stated the social worker had a petty cash fund from which she would give a resident the amount of money needed for a purchase. At the end of the month, money from the resident's account would repay the amount taken from the petty cash fund. MRS stated she did not receive the corporate spreadsheets for the resident accounts and would not know how to read the corporate account spreadsheets. MRS stated she thought Resident 1 received $686 in Social Security payment every month. MRS stated she would only see the $35 deposited into Resident 1's trust fund for incidental purchases. On May 31, 2017, at 9:35 am, a phone interview was conducted with CBO. CBO was asked to explain the notations made on Resident 1's spreadsheet of her corporate account. CBO stated "cash receipt" or "cash receipt-RFMS" would indicate Social Security payments to Resident 1. CBO stated the funds are posted to any month, there are no rules. As an example, CBO stated funds that came in March 2016 could be posted to January 2015. The notation, "Room Charge" was the notation used to indicate a share of cost. CBO stated funds held for a resident in the corporate account would not receive any interest. CBO stated Resident 1 did not receive any interest on the $13,000 held in the corporate account. CBO stated the Administrator at the facility would receive a monthly statement of the funds in the resident's corporate account. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JRGJ11 Facility ID: CA240000092 If continuation sheet 11 of 13 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: _______________ 056229 (X3) DATE SURVEY COMPLETED 08/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALM SPRINGS HEALTHCARE & REHABILITATION CENTER 277 S Sunrise Way Palm Springs, CA 92262 (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 May 31, 2017, at 10:35 am, a phone interview was conducted with ADM 1. ADM 1 stated as administrator she does receive monthly statements for each residents funds held in a corporate account. ADM 1 stated she was not aware of any resident receiving interest on their funds. ADM 1 stated, "That's the way it has always been done." On June 20, 2017, at 11:35 am, an interview was attempted with Resident 1 with the assistance of Health Facilities Evaluator Nurse (HEFN 1) as Spanish interpreter. Resident 1 was able to state her name, time of day, and name of facility she is currently living. Resident 1 stated she remembered the previous facility. Resident 1 stated she had problems with her money at the previous facility every month. Resident 1 stated she did not want to talk about the money or anything else. On June 20, 2017, at 11:45 am, an interview was conducted with Administrator 2 (ADM 2) of the facility where Resident 1 currently resides. ADM 2 stated Resident 1 would lose her MediCal funding for health care as a result of the funds that were being placed in her trust fund at this facility. ADM 2 stated this may result in Resident 1 needing to pay privately for her care. On June 22, 2017, the facility policy and procedure (P&P) dated November 15, 2001, and titled, "Resident Trust Accounts" was reviewed. The P&P indicated, "The resident trust fund is managed by the facility and is kept in an interest bearing account..." The P&P also indicated, "1. When the Resident's account approaches the state limit FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JRGJ11 Facility ID: CA240000092 If continuation sheet 12 of 13 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: _______________ 056229 (X3) DATE SURVEY COMPLETED 08/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALM SPRINGS HEALTHCARE & REHABILITATION CENTER 277 S Sunrise Way Palm Springs, CA 92262 (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 balance within $200 under the limit), the facility's Social services Department or designee must notify the resident and/or responsible part. 2. In the case of excess resources, appropriate actions must be taken as necessary according to specific state regulations." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JRGJ11 Facility ID: CA240000092 If continuation sheet 13 of 13