Other·August 17, 2018

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 investigation of one facility reported incident. Facility reported incident number: CA00571238 Representing the California Department of Public Health: Surveyor 36153, 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 CA00571238.

F600 SS=G Free from Abuse and Neglect CFR(s): 483.12(a)(1)

F600 07/10/2018 §483.12 Freedom from Abuse, Neglect, and Exploitation 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 medical symptoms. §483.12(a) The facility must§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: 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: 66ZQ11 Facility ID: CA240000723 If continuation sheet 1 of 6 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: _______________ 555403 (X3) DATE SURVEY COMPLETED 06/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MONTEREY PALMS HEALTH CARE CENTER 44610 Monterey Ave Palm Desert, CA 92260 (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 Based on observation, interview, and record review, the facility failed to provide an environment free from mental abuse for Resident A, when Certified Nursing Assistant (CNA) 1, while providing care to Resident A, used a cellular telephone to record a video of Resident A showing his genital area. In addition, CNA 1 made inappropriate comments related to the video, and distributed the video through social media. This failure resulted in mental abuse to Resident A by CNA 1. Findings: On January 30, 2018, an unannounced visit was conducted to investigate a facility-reported incident regarding a short video clip of Resident A, with exposed genital area that was posted in social media by CNA 1. On January 30, 2018, at 10:45 a.m., the Director of Nursing (DON) was interviewed. The DON stated she received a telephone call from a non-employee of the facility. The person told the DON that he received a copy of a video clip sent by a friend of one of the facility staff (later identified as CNA 1) via Snapchat (an image messaging and multimedia mobile application used for creating messages referred to as "snaps" [consisting of a photo or a short video of up to 10 seconds]). The DON further stated that about the same time, the Administrator received a telephone call from the friend of CNA 1 who also received the Snapchat video clip. On January 30, 2018, at 11:25 a.m., the Administrator was interviewed. The Administrator stated on January 29, 2018, at around 8:45 a.m., he received a telephone call from the friend of CNA 1, informing him that a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 66ZQ11 Facility ID: CA240000723 If continuation sheet 2 of 6 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: _______________ 555403 (X3) DATE SURVEY COMPLETED 06/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MONTEREY PALMS HEALTH CARE CENTER 44610 Monterey Ave Palm Desert, CA 92260 (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 Snapchat video clip of one of the facility's residents was sent to her by CNA 1. The friend of CNA 1 told the Administrator that she thought it was a wrong thing to do and should have not been done. The Snapchat video clip was forwarded to the Administrator. On January 30, 2018, at 11:30 a.m., the Snapchat video clip was observed together with the Administrator. The Snapchat video clip (approximately a total of 10 seconds long) showed a video selfie (a video that one has taken of oneself using a smartphone and shared via social media) taken by CNA 1 on January 27, 2018. The first scene of approximately 3 seconds long showed CNA 1's face and followed with the statement, "You think we have it easy. This is what we have to deal with every fucking day." The second scene of approximately 5 seconds long, showed Resident A lying in bed with a shirt on but without pants. Resident A's left leg crossedover his bended right knee, with his genital area exposed. The scene included a close-up view of about two seconds of Resident A's genital area. Resident A's face was seen from a distant view on the video. The third scene of about 2 seconds long showed the faces of CNA 1 and Licensed Vocation Nurse (LVN) 1, laughing at the scene that was just taken on video. During a concurrent interview and record review, the Administrator presented a signed and documented "Interview Record" he conducted with CNA 1 on January 29, 2018. The Administrator stated he showed the video clip to CNA 1. CNA 1 admitted it was the video clip she took and posted in Snapchat and sent to an acquaintance who was not a staff of the facility. The Administrator further stated CNA 1 was aware of the company's policy of not using cellphone while in resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 66ZQ11 Facility ID: CA240000723 If continuation sheet 3 of 6 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: _______________ 555403 (X3) DATE SURVEY COMPLETED 06/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MONTEREY PALMS HEALTH CARE CENTER 44610 Monterey Ave Palm Desert, CA 92260 (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 areas. During the concurrent interview and record review, the Administrator presented another signed and documented "Interview Record" he conducted with LVN 1 on January 29, 2018. The Administrator stated LVN 1 entered Resident A's room to administer a medication to Resident A's roommate. LVN 1 noticed Resident A was not wearing a brief and his genital area was exposed. LVN 1 went to the hallway and asked CNA 1 to assist in getting Resident A dressed. After administering the medication to Resident A's roommate, she noticed CNA 1 had her cellphone out. LVN 1 stated she did not know that CNA 1 was taking a video of Resident A. LVN 1 thought CNA 1 was taking a selfie photo of herself. The Administrator stated LVN 1 should have investigated and reported the incident to the nurse supervisor immediately. During a concurrent interview, the Administrator stated he spoke with Resident A's wife on January 29, 2018. The Administrator told Resident A's wife about the video. The Administrator stated after explaining to her the nature of the video, Resident A's wife was shocked. She could hardly believe two facility staff (CNA 1 and LVN 1) she had learned to like because of the care they have done to her husband, could do such a thing. On January 30, 2018, Resident A's record was reviewed. Resident A was admitted to the facility on January 25, 2017, with diagnoses that included dementia (memory loss), diabetes mellitus (high blood sugar), hypertension (elevated blood pressure), and anxiety disorder. Resident A's wife was the responsible party. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 66ZQ11 Facility ID: CA240000723 If continuation sheet 4 of 6 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: _______________ 555403 (X3) DATE SURVEY COMPLETED 06/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MONTEREY PALMS HEALTH CARE CENTER 44610 Monterey Ave Palm Desert, CA 92260 (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 Minimum Data Set (MDS - an assessment tool) dated November 4, 2017, was reviewed. The MDS indicated Resident A can understand others and had the ability to make himself understood. Resident A was alert and oriented with episodes of forgetfulness and confusion. His cognitive skills for daily decision making was moderately impaired. Resident A's functional status required extensive assistance of one-person assist for toileting and bathing, limited assistance for hygiene and dressing, and independent in eating with setup help only from the staff. Resident A's balance during transition and walking was not steady, but able to stabilize without staff assistance using a walker or a wheelchair. On March 20, 2018, the Riverside County Sheriff's (RCS) incident report, dated February 7, 2018, was reviewed. The police report documented, "...(Name of Administrator) allowed me to review the video on his cellphone with him present. I observed (name of CNA 1) who stated, "You think we have it easy, this is what we have to deal with every fucking day." During (name of CNA 1) statement, she turned the view of the video towards (name of Resident A) who was wearing only a shirt and appeared to be sleeping and unaware of what was taking place. The video zoomed in on (name of Resident A) genitals and penis while (name of CNA 1) and (name of LVN 1) are heard laughing in the background. (Name of LVN 1) was heard saying, "Hello" as the video zoomed in on (name of Resident A) genitals and penis. The view of the video turns back around where (name of CNA 1) and (name of LVN 1) as seen still laughing..." The police report further documented, "I contacted (name of Resident A) wife, (name of Resident A's wife), who was at the location FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 66ZQ11 Facility ID: CA240000723 If continuation sheet 5 of 6 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: _______________ 555403 (X3) DATE SURVEY COMPLETED 06/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MONTEREY PALMS HEALTH CARE CENTER 44610 Monterey Ave Palm Desert, CA 92260 (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 after being notified by (name of Administrator) of the incident involving her husband. (Name of Resident A's wife) stated she is the responsible party for all decisions regarding her husband because he suffers from dementia and is unable to care for himself. (Name of Resident A's wife) stated due to being shocked and distraught after hearing what had happened to her husband she was unable to make the decision on whether or not she wanted to file charges against (name of CNA 1)..." On March 22, 2018, the facility's policy titled "Abuse and Neglect Prohibition,'' revised May 2013, was reviewed. The policy indicated, "Each resident has the right to be free from...abuse...Mental abuse include, but is not limited to humiliation..." On March 22, 2018, the facility's policy titled "Resident Dignity & Privacy," was reviewed. The policy indicated, "The facility provides care for residents in a manner that respects and enhances each resident's dignity, individuality, and right to personal privacy...Drape and dress residents appropriately at all times to avoid exposure and embarrassment..." On January 30, 2018, the undated facility policy for "Cell Phone Use," was reviewed. The policy indicated, "...employees are strictly prohibited from using cell phones...on work time and in resident care areas at all times..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 66ZQ11 Facility ID: CA240000723 If continuation sheet 6 of 6