Other·April 18, 2019

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 facility reported incident. Facility Reported Incident # CA00603364. Representing the California Department of Public Health: Surveyor 37536, 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. Two deficiencies were issued for facility reported incident number CA00603364.

F607 SS=D Develop/Implement Abuse/Neglect Policies CFR(s): 483.12(b)(1)-(3)

F607 04/12/2019 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95, This REQUIREMENT is not met as evidenced 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: ZH8M11 Facility ID: CA240000299 If continuation sheet 1 of 10 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: _______________ 555247 (X3) DATE SURVEY COMPLETED 03/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RANCHO MIRAGE HEALTH AND REHABILITATION CENTER 39950 Vista Del Sol Rancho Mirage, CA 92270 (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 by: Based on interview and record review, the facility failed to implement the facility abuse policy and procedure, when the allegations of abuse involving one of the three sampled residents (Resident 1) were not investigated and reported to the appropriate state agencies in a timely manner, in accordance to the facility policy and procedure. This deficient practice had the potential to expose the residents of the facility in an environment of abuse and mistreatment. Findings: On September 24, 2018, at 8:45 a.m., an unannounced visit to the facility was conducted to investigate a facility reported incident related to Resident 1's fall incident. Resident 1's record was reviewed. Resident 1 was admitted to the facility on February 1, 2018, with diagnoses which included muscle weakness and Alzheimer's disease (progressive loss of brain cells that leads to memory loss and the decline of other thinking skills). Resident 1's "Behavior Note," dated September 2, 2018, indicated, "...The patient then started yelling that she wanted the nurse, came out into the hallway and began yelling out for the nurse to come and help her because "they" (the Certified Nursing Assistant/CNA) had "yanked her out of bed, then ripped all the covers off..." Resident 1's "Health Status Note," dated September 4, 2018, indicated, "pt (patient) seemed very confused, refused care from staff, did not seem her normal self, slight anxiety (feeling of worry, uneasiness, and fear) still present blaming staff for ripping off her clothes FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZH8M11 Facility ID: CA240000299 If continuation sheet 2 of 10 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: _______________ 555247 (X3) DATE SURVEY COMPLETED 03/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RANCHO MIRAGE HEALTH AND REHABILITATION CENTER 39950 Vista Del Sol Rancho Mirage, CA 92270 (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 and forcing her to go to bed night before..." Resident 1's "Behavior Note," dated September 5, 2018, indicated, "...pt making statements that someone wearing orange had put their hands on her and she had bruising, ADON (Assistant Director of Nursing) and charge nurse went in to assess body no new marks present..." Resident 1's IDT (Interdisciplinary Team) review notes dated September 11, 2018, indicated a review of the fall incident for Resident 1. The notes further indicated the interventions recommended by the IDT related to the fall. Resident 1's IDT review notes dated September 12, 2018, indicated a follow-up review on Resident 1's fall. The two IDT review notes dated September 11, and 12, 2018, did not indicate a review of Resident 1's allegation statements on September 2, 4, and 5, 2018, against the staff. On September 24, 2018, at 12:11 p.m., the Director of Nursing (DON) was interviewed, The DON stated the statements made by Resident 1 on September 2, 4, and 5, 2018 were her delusions, part of her behavior. The DON stated the statements made by Resident 1 were not reported to the Administrator (ADM abuse coordinator) since the statements were part of Resident 1's delusional behavior and not an allegations of abuse. The DON further stated there was no investigations conducted when it happened. On October 4, 2018, at 8:41 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated she was working on September 4 and 5, 2018, when Resident 1 made a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZH8M11 Facility ID: CA240000299 If continuation sheet 3 of 10 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: _______________ 555247 (X3) DATE SURVEY COMPLETED 03/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RANCHO MIRAGE HEALTH AND REHABILITATION CENTER 39950 Vista Del Sol Rancho Mirage, CA 92270 (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 statement regarding staff ripping off her clothes. In addition, Resident 1 alleged that someone wearing orange had put their hands on her, causing her to bruise. LVN 1 further stated she reported it to the ADON and to the DON the day it happened (September 4 and 5, 2018). On October 4, 2018, at 8:54 a.m., the DON was interviewed. The DON stated the incident on September 2, 4, and 5, 2018, were investigated on September 12, 2018 (seven days after Resident 1 made the statements of allegation). The DON further stated the incident (referring to September 2, 4, and 5, 2018) were not reported to the State survey agency. On October 14, 2018, at 3:03 p.m., the ADON was interviewed. The ADON stated she was working on September 2, 2018, when Resident 1 stated the CNA yanked her out of bed. The ADON stated she did not report the incident to the ADM or to the DON. The ADON was asked if the statement made was an allegation of abuse, the ADON stated "Yes...I guess so." The ADON stated if there was an allegation of abuse, it had to be reported right away. On December 4, 2018, at 9:18 a.m., the ADM was interviewed. The ADM stated the three incidents on September 2, 4, and 5, 2018, were not reported to him by the licensed nurses. The ADM stated the statements made by Resident 1 were not an allegations of abuse. The ADM stated an investigation would be started immediately if it was a clear abuse. The ADM further stated the statements made by Resident 1 were false statements so an investigation was not started right away and the investigation was done on September 12, 2018 (seven days after last report of an abuse allegation). The facility policies and procedures were FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZH8M11 Facility ID: CA240000299 If continuation sheet 4 of 10 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: _______________ 555247 (X3) DATE SURVEY COMPLETED 03/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RANCHO MIRAGE HEALTH AND REHABILITATION CENTER 39950 Vista Del Sol Rancho Mirage, CA 92270 (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 reviewed: -"Reporting Abuse to State Agencies and Other Entities/Individuals," dated December 2009, indicated, "All suspected violations and all substantiated incidents of abuse will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law...Should a suspected violation or substantiated incident of mistreatment, neglect, injuries of an unknown source, or abuse (including resident to resident abuse) be reported, the facility Administrator, or his/her designee, will promptly notify the following persons or agencies...The State licensing/certification agency..." -"Abuse Investigations," dated December 2009, indicated, "All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management...should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident...Investigation Process... a. Review the completed documentation forms; b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident (as medically appropriate); f. Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition; g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZH8M11 Facility ID: CA240000299 If continuation sheet 5 of 10 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: _______________ 555247 (X3) DATE SURVEY COMPLETED 03/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RANCHO MIRAGE HEALTH AND REHABILITATION CENTER 39950 Vista Del Sol Rancho Mirage, CA 92270 (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 h. Interview the resident's roommate, family members, and visitors; i. Interview other residents to whom the accused employee provides care or services; and j. Review all events leading up to the alleged incident..."

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

F609 04/12/2019 §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 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZH8M11 Facility ID: CA240000299 If continuation sheet 6 of 10 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: _______________ 555247 (X3) DATE SURVEY COMPLETED 03/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RANCHO MIRAGE HEALTH AND REHABILITATION CENTER 39950 Vista Del Sol Rancho Mirage, CA 92270 (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 by: Based on interview and record review, the facility failed to ensure the allegations of physical abuse, for one of three sampled residents (Resident 1), were reported to California Department of Public Health (CDPH) not later than two hours after the allegations were made. This failure had the potential to delay the identification and implementation of appropriate action placing the resident at risk for further abuse. Findings: On September 24, 2018, at 8:45 a.m., an unannounced visit to the facility was conducted to investigate a facility reported incident. Resident 1's record was reviewed. Resident 1 was admitted to the facility on February 1, 2018, with diagnoses which included muscle weakness and Alzheimer's disease (progressive loss of brain cells that leads to memory loss and the decline of other thinking skills). Resident 1's "Behavior Note," dated September 2, 2018, indicated, "...The patient then started yelling that she wanted the nurse, came out into the hallway and began yelling out for the nurse to come and help her because "they" (the CNA) had "yanked her out of bed, then ripped all the covers off..." Resident 1's "Health Status Note," dated September 4, 2018, indicated, "pt. (patient) seemed very confused, refused care from staff, did not seem her normal self, slight anxiety (feeling of worry, uneasiness, and fear) still present blaming staff for ripping off her clothes and forcing her to go to bed night before..." Resident 1's "Behavior Note," dated September FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZH8M11 Facility ID: CA240000299 If continuation sheet 7 of 10 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: _______________ 555247 (X3) DATE SURVEY COMPLETED 03/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RANCHO MIRAGE HEALTH AND REHABILITATION CENTER 39950 Vista Del Sol Rancho Mirage, CA 92270 (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 5, 2018, indicated, "...pt. making statements that someone wearing orange had put their hands on her and she had bruising, ADON (Assistant Director of Nursing) and charge nurse went in to assess body no new marks present..." There was no documentation a follow-up was conducted to these statements. Resident 1's IDT (Interdisciplinary Team) review notes dated September 11, 2018, indicated a review of the fall incident for Resident 1. The notes further indicated the interventions recommended by the IDT related to the fall. Resident 1's IDT review notes dated September 12, 2018, indicated a follow-up review on Resident 1's fall. The two IDT review notes dated September 11, and 12, 2018, did not indicate a review of Resident 1's allegation statements on September 2, 4, and 5, 2018, against the staff. On September 24, 2018, at 11:34 a.m., the Director of Nursing (DON) was interviewed. The DON stated allegations of abuse should be reported within two hours. The DON further stated if it was a potential abuse, the incident has to be reported to the Administrator (ADM abuse coordinator). In a concurrent review of the "Behavior Note" and "Health Status Note," with the DON, the DON stated she was aware of the statements made by Resident 1 on September 2, 4, and 5, 2018. On September 24, 2018, at 12:11 p.m., the DON was again interviewed. The DON stated the statements made by Resident 1 on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZH8M11 Facility ID: CA240000299 If continuation sheet 8 of 10 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: _______________ 555247 (X3) DATE SURVEY COMPLETED 03/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RANCHO MIRAGE HEALTH AND REHABILITATION CENTER 39950 Vista Del Sol Rancho Mirage, CA 92270 (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 September 2, 4, and 5, 2018, were her delusions and were part of her behavior. She stated these incidents were not reported to the Administrator. On October 4, 2018, at 8:41 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated she was working on September 4 and 5, 2018, when Resident 1 made the statements blaming staff of ripping her clothes. In addition, she stated the resident alleged someone wearing orange had put their hands on her causing her to bruise. LVN 1 stated she reported the concern to the (ADON) and the DON the day it happened (September 4 and 5, 2018). On October 4, 2018, at 8:54 a.m., the DON was interviewed. The DON stated the incidents on September 2, 4, and 5, 2018, were investigated on September 12, 2018 (seven days after last report of allegation). The DON further stated the incidents were not reported to CDPH. On October 14, 2018, at 3:03 p.m., the ADON was interviewed. The ADON stated she was working on September 2, 2018, when Resident 1 stated the CNA yanked her out of bed. The ADON stated she did not report the incident to the ADM or to the DON. The ADON was asked if the statement made was an allegation of abuse, the ADON stated "Yes...I guess so." The ADON stated it there was an allegation of abuse, it had to be reported right away. On December 4, 2018, at 9:18 a.m., the ADM was interviewed. The ADM stated the three incidents were not reported to him by the licensed nurses. The ADM stated if it were an allegations of abuse, the allegations should be reported to CDPH. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZH8M11 Facility ID: CA240000299 If continuation sheet 9 of 10 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: _______________ 555247 (X3) DATE SURVEY COMPLETED 03/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RANCHO MIRAGE HEALTH AND REHABILITATION CENTER 39950 Vista Del Sol Rancho Mirage, CA 92270 (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 facility's policies and procedures titled, "Reporting Abuse to State Agencies and Other Entities/Individuals," dated December 2009 was reviewed. The policy and procedure indicated, "All suspected violations and all substantiated incidents of abuse will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law...Should a suspected violation or substantiated incident of mistreatment, neglect, injuries of an unknown source, or abuse (including resident to resident abuse) be reported, the facility Administrator, or his/her designee, will promptly notify the following persons or agencies...The State licensing/certification agency...Verbal/written notices to agencies will be made within two (2) hours of the occurrence of such incident and such notice may be submitted via special carrier, fax, e-mail, or by telephone..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZH8M11 Facility ID: CA240000299 If continuation sheet 10 of 10