Other·November 28, 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 an abbreviated standard survey for the investigation of one complaint. Complaint # CA00594639 Representing the California Department of Public Health: Surveyor Federal/State ID# 34435/2829, HFEN The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Deficiency was issued for complaint number CA00594639.

F623 SS=E Notice Requirements Before Transfer/Discharge CFR(s): 483.15(c)(3)-(6)(8)

F623 08/21/2018 §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 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: 80PE11 Facility ID: CA240000092 If continuation sheet 1 of 7 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 08/01/2018 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 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 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; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 80PE11 Facility ID: CA240000092 If continuation sheet 2 of 7 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 08/01/2018 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 (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. §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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 80PE11 Facility ID: CA240000092 If continuation sheet 3 of 7 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 08/01/2018 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 facility failed to ensure, for seven (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6 and Resident 7) out of seven sampled facility initiated-discharged home residents: 1. The resident and the resident's representative were provided with a written notice containing all the required information prior to discharge, and; 2. Copies of the written notice were sent to the Office of the State Long-Term Care Ombudsman. These failures resulted in potential for the seven residents to have not had access to their rights and to have been inappropriately discharged. Findings: On July 20, 2018, at 11:30 a.m., an unannounced complaint investigation was conducted at the facility. The records of the following residents record were were reviewed with the Social Services Director (SSD): 1. Resident 1 was admitted in the facility on March 9, 2018 and discharged home on June 28, 2018. There was no documented evidence in Resident 1's record that a written notice containing all the required information was provided to the resident and the resident's representative prior to discharge. 2. Resident 2 was admitted in the facility on March 30, 2018 and discharged home on July 10, 2018. There was no documented evidence in Resident 2's record that a written notice containing all the required information was provided to the resident and the resident's representative prior to discharge. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 80PE11 Facility ID: CA240000092 If continuation sheet 4 of 7 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 08/01/2018 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 3. Resident 3 was admitted in the facility on June 27, 2018 and discharged to a board and care home on July 8, 2018. There was no documented evidence in Resident 3's record that a written notice containing all the required information was provided to the resident and the resident's representative prior to discharge. 4. Resident 4 was admitted in the facility on July 5, 2018 and discharged home on July 13, 2018. There was no documented evidence in Resident 4's record that a written notice containing all the required information was provided to the resident and the resident's representative prior to discharge. 5. Resident 5 was admitted in the facility on June 6, 2018 and discharged home on July 13, 2018. There was no documented evidence in Resident 5's record that a written notice containing all the required information was provided to the resident and the resident's representative prior to discharge. 6. Resident 6 was admitted in the facility on July 2, 2018 and discharged home on July 16, 2018. There was no documented evidence in Resident 6's record that a written notice containing all the required information was provided to the resident and the resident's representative prior to discharge. 7. Resident 7 was admitted in the facility on June 29, 2018 and discharged home on July 17, 2018. There was no documented evidence in Resident 1's record that a written notice containing all the required information was provided to the resident and the resident's representative prior to discharge. In a concurrent interview with SSD, the SSD stated she was not aware of the required FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 80PE11 Facility ID: CA240000092 If continuation sheet 5 of 7 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 08/01/2018 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 written notice to be provided to residents who were to be discharged by the facility. The SSD confirmed there was no documented evidence, in the records of Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, and Resident 7, that a written notice containing all the required information was provided prior to the discharge. The SSD also confirmed there was documented evidence in the records that notices of the seven discharged residents were sent to the Office of the State Long-Term Care Ombudsman. On July 20, 2018, at 2 p.m., the facility policy and procedure, "Transfer & Discharge," released 04/07/2003, was reviewed with the Director of Nursing (DON). The DON stated, they have not been giving written notices with the required information to the residents they have discharged. The DON stated the staff did not know of the requirement. The DON stated she confirmed with the facility consultant and the consultant said they did not provide the required written notice prior to discharge. The policy and procedure indicated, "...At least prior to transfer or discharge, notify the resident, and if known, the family member, surrogate, or resident representative of the transfer and the reasons for the move...Provide the information in writing and in a language and manner they understand...Explain the resident's right to appeal the transfer/discharge...Provide the name, address, and phone number...Exceptions to the 30 day , requirement...When a resident's health has improved to allow a more immediate transfer or discharge...When a resident has not resided in the facility for 30 days...In these cases, provide the notice as soon as practicable before the transfer/discharge..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 80PE11 Facility ID: CA240000092 If continuation sheet 6 of 7 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 08/01/2018 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 July 20, 2018, at 3:52 p.m., a telephone interview was conducted Ombudsman assigned to the facility. The Ombudsman stated she informed the facility of the requirement to send copies of the written notice to their office more than three months ago. The Ombudsman stated the facility has been informed multiple times but the Office of the State Long-Term Care Ombudsman has not received copies of notices from the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 80PE11 Facility ID: CA240000092 If continuation sheet 7 of 7