Other·April 15, 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 a re-certification survey conducted from September 24, 2018 to October 1, 2018. A Substandard Quality of Care was identified on September 27, 2018, and an extended survey was announced to the facility on September 27, 2018. Representing the California Department of Public Health: Surveyor 37537, HFEN; Surveyor 36684, HFEN; Surveyor 36153, HFEN Surveyor 25281, Pharmacy Consultant Surveyor 38479, HFEN Surveyor 39503, HFEN The facility census was 91 residents.

F561 SS=D Self-Determination CFR(s): 483.10(f)(1)-(3)(8)

F561 10/28/2018 §483.10(f) Self-determination. The resident has the right to and the facility must promote and facilitate resident selfdetermination through support of resident choice, including but not limited to the rights specified in paragraphs (f)(1) through (11) of this section. §483.10(f)(1) The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her 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: B8UC11 Facility ID: CA240000723 If continuation sheet 1 of 140 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 10/01/2018 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 interests, assessments, and plan of care and other applicable provisions of this part. §483.10(f)(2) The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident. §483.10(f)(3) The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility. §483.10(f)(8) The resident has a right to participate in other activities, including social, religious, and community activities that do not interfere with the rights of other residents in the facility. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, for one of 19 residents reviewed (Resident 394), the facility failed to facilitate and accommodate the resident's selfdetermination to make her own choices, when a Certified Nursing Assistant (CNA) denied Resident 394's request to have a shower. This failure had the potential to result in Resident 394 not to be given the opportunity to exercise her right to make choices while at the facility, and could negatively impact her mental and psychosocial well-being. Findings: On September 25, 2018, at around 10:05 a.m., Resident 394 was observed in her room, awake, alert, and oriented, while sitting at the side of her bed. In a concurrent interview, Resident 394 stated, on September 24, 2018, at around 9 a.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 2 of 140 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 10/01/2018 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 while CNA 1 was taking her vital signs, Resident 394 told CNA 1 she needed a shower that day. CNA 1 told Resident 394 she will look at her shower schedule and will come back to check on the resident. Resident 394 stated CNA 1 never came back and checked on her again that day. Resident 394 stated she felt uncomfortable that day because her hair "felt dirty." On September 25, 2018, Resident 394's record was reviewed. Resident 394 was admitted on September 2, 2018. The history and physical indicated Resident 394 had the capacity to understand and make decisions. The Minimum Data Set (MDS- an assessment tool) on admission, dated September 12, 2018, indicated Resident 394 required physical help with one person assist in bathing. On September 25, 2018, at 10:38 a.m., CNA 1 was interviewed. CNA 1 stated she took Resident 394's vital signs on September 24, 2018, during the morning shift. CNA 1 further stated she did not recall if Resident 394 had requested a shower that day. On September 26, 2018, at 9:10 a.m., Resident 394's shower schedule was reviewed with Minimum Data Set/Licensed Vocational Nurse (MDS/LVN) 1. Resident 394's shower schedule indicated her schedule was every Tuesday and Friday, in the afternoon shift. The facility's document titled, "Shower Day Skin Inspection," indicated Resident 394 received a shower on September 18, 2018 (Tuesday). There was no documented evidence Resident 394 recived a shower as scheduled on September 21, 2018 (Friday). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 3 of 140 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 10/01/2018 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 In a concurrent interview, MDS/LVN 1 stated there was no documented evidence Resident 394 received a shower on September 21, 2018 (Friday). MDS/LVN 1 further stated CNA 1 should have accommodated Resident 394's request to have a shower on September 24, 2018 (Monday), even if it was not on her shower schedule day. The facility's policy and procedure titled, "Resident's Rights," dated July 6, 2018, was reviewed. The policy indicated, "Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents...These rights include the resident's rights to...selfdetermination..."

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

F623 10/28/2018 §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 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) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 4 of 140 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 10/01/2018 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 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; (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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 5 of 140 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 10/01/2018 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 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, for three of three residents reviewed for hospitalization (Residents 7, 56, and 76), the facility failed to provide documented evidence the Ombudsman (a goverment official who hears and investigates complaints against maladministration) was notified and provided a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 6 of 140 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 10/01/2018 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 copy of the written notice of transfer of the residents upon hospitalization. This facility failure may result to the residents not to be aware of their rights and priviledges accorded to nursing facility residents, and or resident representative,who was transferred to the hospital for emergency purposes and for the Ombudsman to interviene in a timely manner on behalf of the resident, should the need arise for assistance after the residents were transferred to the hospital. Findings: 1. On September 26, 2018, Resident 7's record was reviewed. Resident 7 was admitted to the facility on October 26, 2016, with diagnoses that included diabetes mellitus (abnormal blood sugar level in the blood) and metabolic encephalopathy (abnormalities of the water and other chemicals that affect brain function). Resident 7's progress note dated April 7, 2018, indicated Resident 7 was transferred to the acute hospital on April 6, 2018 at 10:45 p.m., for further evaluation related to the resident was non verbal and the licensed nurse was unable to obtain a blood pressure. The physician was contacted and ordered transfer to Emergency Room (ER). On September 26, 2018, at 12 p.m., a concurrent interview and record review was conducted with the the Social Services Designee (SSD). The SSD stated there was no documented evidence a copy of written notice of transfer was provided to the Ombudsman when Resident 7 was hospitalized on April 6, 2018. The SSD further stated "It was not completed." 2. On September 26, 2018, at 9:20 a.m., a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 7 of 140 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 10/01/2018 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 concurrent interveiw and record review of Resident 76's record was conducted with Minimum Data Set/Licensed Vocational Nurse (MDS/LVN) 1. Resident 76 was admitted on August 8, 2018, with diagnosis that included unspecified dementia (memory loss), hypertension (high blood pressure), atherosclerotic heart disease, (the arteries of the heart narrows due to build-up of plaque), and diabetes mellitus (elevated blood sugar). Resident 76's progress notes, dated August 19, 2018, indicated Resident 76 complained of chest pain on August 19, 2018, and was sent to the hospital for further treatment and evaluation related to the chest pain. Resident 76 was admitted at the hospital for seven days. Resident 76 was readmitted back to the facility on August 26, 2018. There was no documented evidence a copy of the the written notice of transfer to the hospital on August 19, 2018, was provided to the Ombudsman In a concurrent interview, MDS/LVN 1 stated the Social Services Designee (SSD) was responsible in providing the written Notice of Transfer to the Ombudsman upon residents' hospitalization. On September 28, 2018, at 10:08 a.m., the SSD was interviewed. The SSD stated there was no documented evidence the Ombudsman was informed and provided a written Notice of Transfer, when Resident 76 was hospitalized on August 19, 2018. The SSD further stated she informed the Ombudsman of residents' planned discharges, but she was not aware of the requirement that the Ombudsman had to be informed and sent a copy of the written Notice of Transfer upon residents' hospitalization. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 8 of 140 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 10/01/2018 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 3. On September 28, 2018, at 9:53 a.m., Resident 56's record was reviewed with Minimum Data Set/Licensed Vocational Nurse (MDS/LVN) 2. Resident 56 was admitted on June 17, 2018, with diagnoses that included diabetes mellitus (elevated blood sugar) and non-healing wound of the lower extremities. Resident 56's progress notes dated August 7, 2018, indicated Resident 56 was sent to the hospital on August 7, 2018, for debridement of the non-healing wound on her bilateral lower extremities. Resident 56 was admitted at the hospital for eight days. Resident 56 was readmitted at the facility on August 15, 2018. There was no documented evidence a copy of the written notice of transfer to the hospital on August 7, 2018, was provided to the Ombudsman. In a concurrent interview, MDS/LVN 2 stated the Social Services Designee (SSD) was responsible in providing the written Notice of Transfer to the Ombudsman upon residents' hospitalization. On September 28, 2018, at 10:08 a.m., the SSD was interviewed. The SSD stated she informed the Ombudsman of residents' planned discharges, but she was not aware of the requirement that the Ombudsman had to be informed and sent a copy of the written notice of transfer when a resident was transferred to the hospital. On September 28, 2018, the facility policy and procedure titled, "Transfer & Discharge," dated April 7, 2003, was reviewed with the SSD. The SSD acknowledged the policy did not address the new requirement that the facility must notify and send a copy of the written notice of transfer to the Ombudsman, when a resident is transferred to the hospital. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 9 of 140 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 10/01/2018 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 On October 1, 2018, the facility provided a copy of the policy and procedure titled, "Transfer and Discharge Notice," dated July 7, 2018. The policy indicated, "...A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman..."

F625 SS=D Notice of Bed Hold Policy Before/Upon Trnsfr CFR(s): 483.15(d)(1)(2)

F625 10/28/2018 §483.15(d) Notice of bed-hold policy and return§483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility; (ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any; (iii) The nursing facility's policies regarding bedhold periods, which must be consistent with paragraph (e)(1) of this section, permitting a resident to return; and (iv) The information specified in paragraph (e) (1) of this section. §483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 10 of 140 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 10/01/2018 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 by: Based on interview and record review, for one of three residents (Resident 7) reviewed for hospitalization, the facility failed to ensure a written notice of bed-hold policy was provided to the residents and/or residents representative (RR) within 24 hours of the resident's hospitalization. This failure had the potential for the resident to not be made aware of the facility's bed-hold and reserved bed payment policy upon transfer to the hospital. Findings: On September 26, 2018, Resident 7's record was reviewed. Resident 7 was admitted to the facility on October,26, 2016, with diagnoses that included; diabetes mellitus (abnormal levels of glucose in the blood) and metabolic encephalopathy (abnormalities of the water and other chemicals that affect brain function). Resident 7's grandchild was the RR. Resident 7's progress note dated April 7, 2018, indicated Resident 7 was transferred to the acute hospital on April 6, 2018 at 10:45 p.m., for further evaluation related to the resident was non verbal and the licensed nurse was unable to obtain a blood pressure. The physician was contacted and ordered transfer to Emergency Room (ER). There was no documented evidence a written notice of bed-hold policy was provided to the RR within 24 hours of Resident 7's hospitalization on April 6, 2018. On September 26, 2018 at 12:05 p.m., an interview and record review was conducted with Licensed Vocational Nurse ( LVN) 1. LVN 1 stated the licensed nurse assigned when FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 11 of 140 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 10/01/2018 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 Resident 7 was transferred to the hospital should have provided the RR a written copy of the the bed-hold policy within 24 hours after Resident 7 was hospitalized on April 6, 2018. The facility policy's and procedure titled, "BedHold" dated July 6, 2018, indicated, "...Upon admission and at the time a resident is transferred to a hospital...a facility designee will provide the resident and an immediate family member, surrogate, or representative written information concerning the option to exercise the bed-hold policy..."

F655 SS=D Baseline Care Plan CFR(s): 483.21(a)(1)-(3)

F655 10/28/2018 §483.21 Comprehensive Person-Centered Care Planning §483.21(a) Baseline Care Plans §483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must(i) Be developed within 48 hours of a resident's admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to(A) Initial goals based on admission orders. (B) Physician orders. (C) Dietary orders. (D) Therapy services. (E) Social services. (F) PASARR recommendation, if applicable. §483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 12 of 140 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 10/01/2018 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 plan(i) Is developed within 48 hours of the resident's admission. (ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section). §483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident's medications and dietary instructions. (iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (iv) Any updated information based on the details of the comprehensive care plan, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure one of one resident reviewed (Resident 192) had a complete baseline care plan that included the minimum health care information necessary for the care of the resident in the facility. This failure had the potential for the facility staff not to have the necessary information to promote continuity of care, increase resident's safety, and safeguard against adverse events that most likely to occur right after admission. Findings: On September 24, 2018, Resident 192's record was reviewed. Resident 192 was admitted to the facility on September 15, 2018. Reident 192's history and physical dated September 16, 2018, indicated, "He was found to have cidiff FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 13 of 140 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 10/01/2018 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 colitis (sic - c-diff [Clostridium difficile] bacterial infection that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon) and was treated with antibiotic..." The physician's order dated September 17, 2018, indicated, "...CONTACT ISOLATION D/T (due to) C-DIFF)..." was ordered two days after Resident 192's admission to the facility. There was no documented evidence a baseline care plan was developed for Resident 192's cdiff infection within 48 hours of Resident 192's admission to the facility. On September 25, 2018, at 10:38 a.m., the Minimum Data Set (MDS - resident assessment tool) / Licensed Vocational Nurse (LVN) was interviewed. The MDS/LVN was not able to provide documented evidence a baseline care plan was developed that addressed Resident 192's c-diff infection. The MDS/LVN stated baseline care plan was a way of communication among staff regarding the resident's health and safety concerns. The MDS/LVN stated Resident 192's c-diff infection should have been identified and addressed in the baseline care plan to provide consistency in Resident 192's health care management and to prevent transmission and spread of infection in the facility. MDS/LVN stated a baseline care plan for c-diff infection should have been developed within 48 hours of Resident 192's admission to the facility. On October 1, 2018, the facility's policy and procedure titled, "Baseline Care Plan," dated July 2018, was reviewed. The policy indicated, "...To assure that the resident's immediate needs are met and maintained, a baseline care plan will be developed within forty-eight (48) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 14 of 140 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 10/01/2018 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 hours of the resident's admission... The resident and their representative will be provided a summary of the baseline care plan that includes... Any services and treatments to be administered by the facility..."

F677 SS=D ADL Care Provided for Dependent Residents CFR(s): 483.24(a)(2)

F677 10/28/2018 §483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure for one of 19 residents (Resident 292), assistance with her Activities of Daily Living (ADL - routine activities people do everyday without assistance such as eating, bathing, getting dressed, transferring and toileting) was provided when needed. This failure had the potential for Resident 292 not to receive adequate hygiene care and services needed as assessed to better meet the resident's daily needs. Findings: On September 24, 2018, at 11:13 a.m., a concurrent observation and interview was conducted on Resident 292. Resident 292 was in her room sitting on her wheelchair. Resident 292 stated she goes to the bathroom by herself. During the inspection of Resident 292's bathroom, the toilet seat was observed with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 15 of 140 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 10/01/2018 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 spalsh marks of moderate amount of dried brown substance. Resident 292 stated she had a large bowel movement last night, and she had used the toilet this morning. Resident 292 stated she did not noticed the dried brown substance on the toilet seat. Subsequently, Resident 292 wheeled herself to the sink by the door, slowly stood up to wet the wash cloth she was holding and started to wipe her face and arms with the wet wash cloth. Resident 292 stated she does everything by herself and the nurses does not help her at all. On September 24, 2018, at 11:38 a.m., a concurrent observation and interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated she was the nurse assigned to render care on Resident 292. CNA 2 stated Resident 292 does her ADLs by herself. CNA 2 stated the resident was continent (ability to hold urine and bowel) of her bowel and bladder. CNA 2 further stated she only asked the resident if she had a bowel movement or not on her shift. CNA 2 stated Resident 292's room mate does not use the toilet and Resident 292 was able to use the toilet in her room by herself. CNA 2 observed the dried brown substance on the toilet seat of Resident 292's bathroom. CNA 2 stated she did not know how long it had been there because she had not assisted Resident 292 to use the bathroom since she started her shift for today. On September 25, 2018, Resident 292's record was reviewed with Registered Nurse (RN) 2. Resident 292 was re-admitted to the facility on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 16 of 140 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 10/01/2018 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 May 11, 2018, with diagnoses that included dementia (progressive disease that destroys memory and other mental functions), muscle wekaness, and difficulty in walking. The Minimum Data Set (MDS- an assessment tool) dated August 18, 2018, indicated Resident 292 was an extensive assist (resident involved in activity, staff provide weight-bearing support) and needed one person physical assist in dressing, toilet use, and personal hygiene. The care plan dated May 18, 2018, indicated, "...SELF CARE DEFICIT Requires...Extensive assistance...Due to...Physical limitation/disability...Approach Start Date 05/18/2018 provide assistance needed to the resident including toileting assistance..." In a concurrent interview, RN 2 stated Resident 262 needed a stand by or minimal assist with her ADLs. RN 2 stated she had noticed a gradual decline in Resident 292's ADLS. RN 2 stated Resident 292 needed assistance with her toileting. RN 2 stated the dried brown substance found on Resident 2's toilet seat was dried feces and further stated, "That's not right." RN 2 stated the CNA should have assisted Resident 292 to the bathroom and with her ADLs.

F684 SS=H Quality of Care CFR(s): 483.25

F684 10/28/2018 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 17 of 140 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 10/01/2018 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 assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure 14 of 91 residents reviewed (Residents 44, 61, 74, 17, 76, 9, 28, 56, 57, 197, 90, 43, and 42) receive treatment and care in accordance with professional standards of practice and the comprehensive care plan when: 1. Resident 44 did not received her Fentanyl patch (narcotic pain medication) from September 10 to 15, 2018. This failure resulted for the resident to experienced increase pain. 2. Resident 44, who had unstable high blood sugar levels, did not received her prescribed Levimir insulin (medication to treat diabetes - a disease that result in too much sugar in the blood) on September 22, 2018. In addition, Resident 44's blood sugar level were not checked on August 25, 2018, at 11:30 a.m. and September 22, 2018, at 6:30 a.m. to determine the resident's need to receive Novolin R insulin (medication to treat diabetes). These failures could jeopardize Resident 44's health and safety for having unstable high blood sugar levels. 3. Residents 44, 61, and 74 received their prescribed antihypertensive medications (for treatment of high blood pressure - that is FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 18 of 140 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 10/01/2018 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 140/90 or higher) on multiple occasions in the month of August and September 2018, when the residents' blood pressure reading where below the parameters as indicated on the physician's order. This failure could jeopardize the residents' health and safety when putting the residents at risk for hypotension (low blood pressure - less than 90/60). 4. Resident 44's endocrinology consult (a physician who has special training in diagnosing and treating disorders of the endocrine system) as ordered by the physician on July 25, 2018, for uncontrolled blood sugar levels was not acted upon. This failure resulted for Resident 44's unstable blood sugar levels not assessed and evaluated by the specialize physician. 5. Resident 17 did not received his Methadone (narcotic pain medication) on multiple occasions. This failure resulted for the resident to experienced increase pain. 6. Resident 76 did not received his Methadone on multiple occasions. This failure resulted for the resident to experienced increase pain. 7. Resident 9 did not received her Lyrica (medication that treats nerve and muscle pain) on multiple occasions. This failure resulted for the resident to experienced increase neuropathy pain (nerve pain). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 19 of 140 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 10/01/2018 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 8. Resident 28 did not received her Toradol (pain medication) on multiple occasions. This failure resulted for the resident to experienced increase pain. 9. Resident 56 did not received her Fentanyl patch (narcotic pain medication) and Percocet (narcotic pain medication) on multiple occasions. This failure resulted for the resident to experienced increase pain. 10. Resident 57 did not received his Bactrim (antibiotic for urinary tract infection [UTI]) as a prophylaxis for UTI on multiple occasions. This failure could jeopardize Resident 57's health and safety for putting the resident at risk of developing UTI. 11. Resident 197 did not received his Travatan eye drop (for treatment of glaucoma - eye disease that can cause vision loss and blindness) and Xalatan eye drop (for treatment of glaucoma). This failure could jeopardize Resident 197's health and safety for not receiving the resident's prescribed medication for his glaucoma. 12. Resident 90 did not received her Gabapentin (for neuropathy) on multiple occasions. This failure put the resident at risk to experience increase neuropathy pain. 13. Resident 43 did not received her Morphine (narcotic pain medication) on multiple occasions. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 20 of 140 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 10/01/2018 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 This failure resulted for the resident to experienced increase pain. 14. Resident 42's +3 pitting edema (swelling of a body part, when pressed creates an indentation - measured from +1 = slight indentation to +4 = deep indentation) that was identified on September 4, 2018, had no documented evidence a care plan was developed. This failure resulted for the resident not receiving a comprehensive person-centered care plan that addressed and managed Resident 42's +3 pitting edema. 15. Resident 42's assessment for the used of device for appropriate positioning of resident's flaccid feet related to hemiplegia (paralysis on half of the body) was not conducted. This failure put the resident at risk for skin breakdown and discomfort from the use of inappropriate positioning device. Findings: 1. On September 25, 2018, Resident 44's record was reviewed. Resident 44 was readmitted to the facility on January 8, 2018, with diagnoses that included myalgia (muscle pain), lumbago (low back pain), and chronic pain syndrome. Resident 44 had cognitive decision-making. Resident 44 physician's order indicated, "...fentanyl...patch 72 hour; 12 mcg/hr (microgram/hour)...apply 1 patch transdermal (application of a medication through the skin)...Every 72 Hours; 09:00 AM..." date ordered February 3, 2018. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 21 of 140 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 10/01/2018 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 Resident 44's electronic Medication Administration Record (eMAR) for the month of September 2018, indicated Resident 44's fentanyl patch was scheduled to be changed on September 10, 2018. Further review of Resident 44's eMAR for September 2018, indicated the following: - "...Monitor FENTANYL patch placement Qshift... - 09/10/2018 03:56 PM...waiting on pharmacy to deliver... - 09/12/2018 03:01 PM...PHARMACY WILL FAX (name of doctor) for continuous (sic)... - 09/12/2018 05:18 PM Not Administered: On Hold... - 09/13/2018 02:10 AM Not Administered: On Hold... - 09/13/2018 01:42 PM Not Administered: On Hold... - 09/13/2018 04:20 PM Not Administered: Drug/Item unavailable... - 09/14/2018 01:09 AM Not Administered: Drug/Item unavailable... - 09/15/2018 11:38 AM Not Administered...off..." Resident 44's Fentanyl patch narcotic count sheet with a delivery date of the medication on August 10, 2018, containing 10 patch indicated the 10th patch was used on September 7, 2018. Resident 44's Fentanyl patch narcotic count FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 22 of 140 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 10/01/2018 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 sheet with a delivery date of the medication on September 15, 2018, containing 5 patch indicated the first patch was used on September 16, 2018. There was no documented evidence Resident 44's Fentanyl patch was administered on September 10 to 15, 2018. On September 25, 2018, at 11:50 a.m., Resident 44 was interviewed. Resident 44 stated she was always in pain because of her myalgia. Resident 44 stated her Fentanyl patch was important for her to have so she could manage her pain due to myalgia. Resident 44 stated the fentanyl patch would not completely remove her pain but the medication would helped to bring down her pain on a tolerable level. Resident 44 stated she had several days in the month of September 2018 where she did not have the fentanyl patch. Resident 44 stated the nurses told her the fentanyl patch was not available because the pharmacy was waiting for the physician's authorization. Resident 44 stated her pain level on the days she did not have the fentanyl patch were "8 out of 10" (pain rating scale 0 to 10: 8-10 severe pain). Resident 44 stated because of severe pain she mostly stayed in bed. Resident 44 further stated, "I sleep it off...so not to feel the pain." On October 1, 2018, at 5:38 p.m., a concurrent record review and interview was conducted with Minimum Data Set (MDS - an assessment tool) / Licensed Vocational Nurse (LVN) 2. MDS/LVN 2 verified fentanyl patch was not given to Resident 44 from September 10 to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 23 of 140 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 10/01/2018 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 September 15, 2018, because it was not available. MDS/LVN 2 verified there was no documented evidence Resident 44's pain assessment was conducted on September 10 to 15, 2018. MDS/LVN 2 verified there was no documented evidence MD was notified of the fentanyl patch not administered to Resident 44 when it was not available. On September 28, 2018, at 1:05 p.m., LVN 5 was interviewed. LVN 5 stated she was the nurse assigned to Resident 44 on September 13, 2018. LVN 5 stated Resident 44 was scheduled for a fentanyl patch on that day, but the medication was not available. LVN 5 stated Resident 44 needed her fentanyl patch for pain management. LVN 5 stated the fentanyl patch was not available because the pharmacy was waiting for the physician's authorization. LVN 5 stated she did not followed up with the pharmacy for the status of Resident 44's fentanyl patch refill. LVN 5 stated she should have coordinated with the pharmacy in obtaining the physician's authorization for fentanyl patch order. LVN 5 stated she did not notified the physician when Resident 44's fentanyl patch was not available. LVN 5 stated she should have notified the physician and asked for alternative pain medication when fentanyl patch was not available for Resident 44. LVN 5 stated she did not have documented evidence of Resident 44's pain assessment on September 13, 2018, when she was the assigned nurse. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 24 of 140 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 10/01/2018 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 On September 25, 2018, at 3:15 p.m., the Director of Nursing (DON) was interviewed. The DON stated she was not aware the fentanyl patch for Resident 44 was not available because the pharmacy was waiting for the physician's authorization. The DON stated the nurses should have notified the physician when fentanyl was not available. The DON stated the nurses should have asked the physician for alternative pain medication while fentanyl patch was not available for Resident 44. The DON stated it is not acceptable for Resident 44 not to have the fentanyl patch nor an alternative pain medication for several days. On October 1, 2018, Resident 44's care plan for pain with a reviewed and revised date of September 24, 2018 was reviewed. The care plan for pain indicated, "...Goal...Resident will be pain free or relieved from pain...Approach...Administer pain medication as ordered...Assess level of pain...Consult MD if above measures fail to provide adequate pain relief..." 2. On September 25, 2018, Resident 44's record was reviewed. Resident 44 was readmitted to the facility on January 8, 2018, with diagnoses that included diabetes. Resident 44 had cognitive decision-making. Resident 44 physician's order indicated, - "...Levemir...100 unit/mL (milliliter)...80 units...Once A Day; 06:30 AM..." date ordered July 25, 2018; and - "...Novolin R...per sliding scale (progressive increase on the insulin dose, based on preFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 25 of 140 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 10/01/2018 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 defined blood glucose ranges...Before Meals; 06:30 AM, 11:30 AM, 04:30 PM..." date ordered January 8, 2018. Resident 44's electronic Medication Administration Record (eMAR) for the month of August 2018, indicated the following: - Resident 44's blood sugar was not documented on August 25, 2018, at 11:30 a.m.; - From August 1 to 31, 2018, Resident 44's blood sugar level ranges from 230 mg/dl (milligram/deciliter) to 400 mg/dl (above 126 mg/dl was diabetic); and - Resident 44 was receiving Novolin R every day from August 1 to 31, 2018, at 6:30 a.m., 11:30 a.m., and 4:30 p.m., except on August 25, 2018, at 11:30 a.m. Resident 44's eMAR for the month of September 2018, indicated the following: - Resident 44's blood sugar was not documented on September 22, 2018, at 6:30 a.m. - Resident 44's Levemir insulin was not administered on September 22, 2018, at 6:30 a.m. - From September 1 to 25, 2018, Resident 44's blood sugar level ranges from 262 mg/dl to 461 mg/dl; and - Resident 44 was receiving Novolin R every day from September 1 to 25, 2018, at 6:30 a.m., 11:30 a.m., and 4:30 p.m., except on September 22, 2018, at 6:30 a.m. On October 1, 2018, at 2:37 p.m., a concurrent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 26 of 140 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 10/01/2018 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 record review and interview was conducted with Minimum Data Set (MDS - an assessment tool) / Licensed Vocational Nurse (LVN) 2. MDS/LVN 2 verified: - Resident 44's eMAR for the month of August 2018, had no documented evidence Resident 44's blood sugar level was documented on August 25, 2018, at 11:30 a.m.; and - Resident 44's eMAR for the month of September 2018, had no documented evidence Resident 44's blood sugar level was documented on September 22, 2018 and the Levemir insulin was not administered to the resident on September 22, 2018. MDS/LVN 2 stated if there was no documentation on the eMAR it means the blood sugar was not checked and the insulin was not given. MDS/LVN 2 stated it was important for Resident 44's blood sugar to be checked before each meal, and insulin to be administered as indicated on the physician's order. MDS/LVN 2 further stated monitoring of blood sugar level and administering the prescribed insulin to Resident 44 should be done to help manage the resident's diabetes and to prevent adverse consequences of having a high blood sugar level. On October 1, 2018, Resident 44's care plan for diabetes with a reviewed and revised date of September 27, 2018 was reviewed. The care plan for diabetes indicated, "...Goal...Resident's blood sugar level will remain stable...Resident's sign and symptoms of hypo/hyperglycemia will improve with interventions...Approach...Blood sugar checked as ordered...Follow sliding scale FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 27 of 140 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 10/01/2018 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 if applicable...Insulin as ordered..." The facility's policy and procedure titled, "Medication Administration Times," dated July 6, 2018, indicated, "...Facility should ensure that authorized personnel...administer medications according to times of administration as determined by...physician..." 3a. On September 25, 2018, Resident 44's record was reviewed. Resident 44 was readmitted to the facility on January 8, 2018, with diagnoses that included hypertension (high blood pressure) and congestive heart failure (CHF - a condition that affects the pumping power of the heart muscles). Resident 44 had cognitive decision-making. Resident 44 physician's order indicated, - "...Lisinopril (antihypertensive medication) tablet; 5 mg (milligram)...1 tablet; oral...hold for sbp (systolic blood pressure - the first number on the blood pressure (BP) reading) less than 100...Once A Day; 09:00 AM..." date ordered January 8, 2018; - "...metoprolol (antihypertensive medication) tablet; 100 mg...1 tablet; oral ...hold for sbp less than 100...Twice A Day; 09:00 AM, 05:00 PM ..." date ordered January 8, 2018; - " ...spironolactone (medication for CHF) tablet; 25 mg...0.5 tablet; oral...hold for sbp less than 100...Once A Day; 09:00 AM..." date ordered January 8, 2018; Resident 44's physician's order had no documented evidence the resident's antihypertensive medications were changed nor discontinued after January 8, 2018. Resident 44's electronic Medication FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 28 of 140 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 10/01/2018 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 Administration Record (eMAR) for the month of August 2018, indicated the following: - Resident 44's BP was 98/68 on September 15, 2018 at 5 p.m., the resident was given Metoprolol 100 mg (1 tablet); - Resident 44's BP was 98/62 on September 21, 2018 at 5 p.m., the resident was given Metoprolol 100 mg (1 tablet); and - Resident 44's BP was 92/68 on September 28, 2018 at 9 a.m., the resident was given Lisinopril 5 mg (1 tablet), Metoprolol 100 mg (1 tablet), and Spironolactone 25 mg (1/2 tablet). Resident 44's electronic Medication Administration Record (eMAR) for September 1 to 25, 2018, indicated the following: - Resident 44's BP was 98/62 on September 5, 2018 at 5 p.m., the resident was given Metoprolol 100 mg (1 tablet); - Resident 44's BP was 93/60 on September 7, 2018 at 9 a.m., the resident was given Lisinopril 5 mg (1 tablet); - Resident 44's BP was 98/56 on September 12, 2018 at 5 p.m., the resident was given Metoprolol 100 mg (1 tablet); - Resident 44's BP was 98/72 on September 17, 2018 at 5 p.m., the resident was given Metoprolol 100 mg (1 tablet); and - Resident 44's BP was 98/66 on September 22, 2018 at 9:00 a.m., the resident was given Lisinopril 5 mg (1 tablet), Metoprolol 100 mg (1 tablet), and Spironolactone 25 mg (1/2 tablet). On October 1, 2018, at 9:31 a.m., a concurrent record review and interview was conducted FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 29 of 140 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 10/01/2018 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 with Registered Nurse (RN) 2. RN 2 verified Resident 44 had the following medications: Lisinopril, Metoprolol, and Spironolactone. RN 2 stated Resident 44's antihypertensive medications were not change nor discontinued since the order date of January 8, 2018. RN 2 verified Resident 44's antihypertensive medications were administered on multiple occasions to the resident when Resident 44's BP was below the indicated sbp parameter. RN 2 stated Resident 44 should have not given the antihypertensive medications when her sbp was below indicated parameter. RN 2 stated the resident would be at risk for hypotension. 3b. On September 25, 2018, Resident 61's record was reviewed. Resident 61 was readmitted to the facility on May 21, 2018. Resident 61 was self-responsible. Resident 61 physician's order indicated, "...carvedilol (antihypertensive medication) tablet; 6.25 mg (milligram); oral...for HTN (hypertension - high blood pressure). Hold for sbp (systolic blood pressure - the first number on the blood pressure (BP) reading) < (less than) 120...Twice A Day; 09:00 AM, 05:00 PM..." date ordered May 25, 2018. Resident 61's physician's order had no documented evidence the resident's antihypertensive medications where change nor discontinued after May 25, 2018. Resident 61's electronic Medication Administration Record (eMAR) for the month of August 2018, indicated the following: - Resident 61's BP was 110/70 on August 14, 2018 at 9 a.m., the resident was given FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 30 of 140 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 10/01/2018 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 Carvedilol 6.25 mg; - Resident 61's BP was 108/70 on August 16, 2018 at 9 a.m., the resident was given Carvedilol 6.25 mg; - Resident 61's BP was 110/70 on August 21, 2018 at 9 a.m., the resident was given Carvedilol 6.25 mg; - Resident 61's BP was 107/72 on August 23, 2018 at 5 p.m., the resident was given Carvedilol 6.25 mg; and - Resident 61's BP was 116/69 on August 30, 2018 at 9 a.m., the resident was given Carvedilol 6.25 mg; Resident 61's electronic Medication Administration Record (eMAR) for September 1 to 25, 2018, indicated the following: - Resident 61's BP was 110/70 on September 4, 2018 at 9 a.m., the resident was given Carvedilol 6.25 mg; - Resident 61's BP was 112/68 on September 8, 2018 at 9 a.m., the resident was given Carvedilol 6.25 mg; - Resident 61's BP was 117/62 on September 9, 2018 at 9 a.m., the resident was given Carvedilol 6.25 mg; - Resident 61's BP was 109/58 on September 12, 2018 at 9 a.m., the resident was given Carvedilol 6.25 mg; and - Resident 61's BP was 117/57 on September 14, 2018 at 5 p.m., the resident was given Carvedilol 6.25 mg; On September 28, 2018, at 9:55 a.m., a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 31 of 140 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 10/01/2018 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 concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN) 4. LVN 4 stated when the resident have antihypertensive medication, the blood pressure (BP) should be checked first. LVN 4 stated if the blood pressure reading was below the indicated parameters, the antihypertensive medication should not be given. LVN 4 stated when antihypertensive medication was given to the resident with the blood pressure below indicated parameter, there could be a risk for the resident to have hypotension. LVN 4 verified Resident 61 received Carvedilol on multiple occasions on the month of August and September 2018, when the resident's BP was below indicated parameter. LVN 4 verified she was the nurse, as documented in the eMAR, who administered the Carvedilol to Resident 61 below indicated parameter on the following dates: - August 14, 16, 21, and 30, 2018; and - September 4, 8, and 12, 2018. LVN 4 stated she should have not administered the Carvedilol to Resident 61 when the resident's BP was below indicated parameter. 3c. On September 25, 2018, Resident 74's record was reviewed. Resident 74 was admitted to the facility on February 8, 2018, with diagnoses that included hypertension (high blood pressure). Resident 74 was selfresponsible. Resident 74 physician's order indicated, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 32 of 140 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 10/01/2018 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 - "...atenolol (antihypertensive medication) tablet; 50 mg (milligram)...1 tablet; oral...hold for SBP (systolic blood pressure - the first number on the blood pressure (BP) reading) less than 100...Once A Day; 09:00 AM..." date ordered May 31, 2018; - "...Lasix (antihypertensive medication) tablet; 20 mg...1 tablet; oral...hold for systolic B/P (blood pressure) < 100 Once A Day; 09:00 AM..." date ordered May 31, 2018; and - " ...diltiazem (antihypertensive medication) tablet; 60 mg; oral...hold for SBP less (sic)110 Once A Day; 09:00 AM..." date ordered July 23, 2018. Resident 74 physician's order had no documented evidence the resident's antihypertensive medications where change nor discontinued after the ordered date. Resident 74's electronic Medication Administration Record (eMAR) for the month of August 2018, indicated the following: - Resident 74's BP was 108/60 on August 7, 2018 at 9 a.m., the resident was given Diltiazem 60 mg; - Resident 74's BP was 104/60 on August 10, 2018 at 9 a.m., the resident was given Diltiazem 60 mg; and - Resident 74's BP was 99/77 on August 16, 2018 at 9 a.m., the resident was given Atenolol 50 mg, Diltiazem 60 mg, and Lasix 20mg. On September 28, 2018, at 10 a.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN) 4. LVN 4 stated when the resident have FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 33 of 140 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 10/01/2018 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 antihypertensive medication, the blood pressure (BP) should be checked first. LVN 4 stated if the blood pressure reading was below the indicated parameters, the antihypertensive medication should not be given. LVN 4 stated when antihypertensive medication was given to the resident with the blood pressure below indicated parameter, there could be a risk for the resident to have hypotension. LVN 4 verified Resident 74 received antihypertensive medications on multiple occasions on the month of August 2018, when the resident's BP was below indicated parameter. LVN 4 verified she was the nurse, as documented in the eMAR, who administered the Atenolol, Diltiazem, and Lasix to Resident 61 below indicated parameter on August 16, 2018. LVN 4 stated she should have not administered Resident 61's antihypertensive medications when the resident's BP was below indicated parameter. The facility's policy and procedure titled, "Administering Medications," dated July 6, 2018, indicated, "...Medications shall be administered in a safe and timely manner, and as prescribed...The following information must be checked/verified for each resident prior to administering medications...Vital signs, if necessary..." 4. On September 25, 2018, Resident 44's record was reviewed. Resident 44 was readmitted to the facility on January 8, 2018, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 34 of 140 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 10/01/2018 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 with diagnoses that included diabetes. Resident 44 had cognitive decision-making. Resident 44 physician's order indicated, "...Endocrinology consult...PLS (please) CALL MAKE APPT (appointment)..." date ordered July 25, 2018. Resident 44's electronic Medication Administration Record (eMAR) for the month of August 2018, indicated the following: - From August 1 to 31, 2018, Resident 44's blood sugar level ranges from 230 mg/dl (milligram/deciliter) to 400 mg/dl (above 126 mg/dl was diabetic); - Resident 44 was receiving Levemir insulin 80 units at 6:30 a.m. and 40 units at bedtime; and - Resident 44 was receiving Novolin R every day from August 1 to 31, 2018, three times a day before meals. Resident 44's eMAR for September 1 to 25, 2018, indicated the following: - Resident 44's blood sugar level ranges from 262 mg/dl to 461 mg/dl; - Resident 44 was receiving Levemir insulin 80 units at 6:30 a.m. and 40 units at bedtime; and - Resident 44 was receiving Novolin R every day from September 1 to 25, 2018, three times a day before meals. On October 1, 2018, at 10:35 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated if there were an order for consult, the charge nurse would be the one responsible for the follow up and setting up of the appointment for the resident. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 35 of 140 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 10/01/2018 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 LVN 1 stated if there would be a need for insurance approval before making the consult appointment, the charge nurse would refer it to the social services. LVN 1 stated there was no documented evidence an appointment was made for Resident 44's endocrinology consult that was ordered on July 25, 2018 nor a reason for not obtaining the consult appointment. LVN 1 stated the charge nurse who received the endocrinology consult should have made an appointment. LVN 1 stated it was important to schedule Resident 44's endocrinology consult because of the resident's uncontrolled high blood sugar levels. The facility's policy and procedure titled, "Referral to Outside Agencies," dated July 6, 2018, indicated, "...Referrals can be made by the Social Services Director, licensed nurse, or a member of the IDT based on a resident's individualized, specific needs identified through interviews, evaluations, and assessments..." 5. On September 27, 2018, Resident 17's record was reviewed. Resident 17 was admitted to the facility on December 16, 2016, with diagnoses that included unspecified pain. Resident 17's electronic Medication Administration Record (eMAR) for the month of September 2018, was reviewed . The physician's orders in the eMAR indicated Methadone tablet 5 mg (milligrams) to administer 0.5 mg tablet by mouth every 12 hours for pain management with the goal of "pain level of 0-2/10 (0-2 in a scale of 0-10 being 10 the worst pain)." Further review of Resident 17's eMAR indicated, the resident did not receive his FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 36 of 140 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 10/01/2018 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 Methadone dose on the following dates: - September 15, 16, and 18, 2018 at 9 a.m. and 9 p.m. - September 19, 2018 the dose at 9 a.m. On September 27, 2018 at 10 a.m., an interview was conducted with Licensed Vocational Nurse (LVN) 2. LVN 2 stated when medications are not available, the licensed nurse should call the pharmacy and asks when the facility is going to receive the medication. LVN 2 further stated she follows up with pharmacy usually after rounds and calls the pharmacy again at the end of the shift. On September 28, 2018, at 11:20 a.m., a concurrent interview and record review was conducted with LVN 3. LVN 3 verified the Methadone doses were not administered to Resident 17 on September 15, 16, 18, and 19, 2018. LVN 3 stated there was no assessment for pain conducted on September 15, 16, 18, and 19, 2018 for Resident 17. On October 1, 2018 at 10:35 a.m., an interview was conducted with Resident 17. Resident 17 stated he was aware and was notified Methadone was not available by the licensed nurses. Resident 17 stated when he did not received his Methadone, his pain scale was 8 out of 10. Resident 17 further stated it was generalized pain and "It was very bad pain for several days." 6. On September 28, 2018, at 10:33 a.m., Resident 76's record was reviewed with Minimum Data Set (MDS - an assessment tool) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 37 of 140 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 10/01/2018 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 / Licensed Vocational Nurse (LVN) 2. Resident 76 was admitted to the facility on August 8, 2018, with diagnoses that included pain in unspecified lower leg, low back pain, fracture of the right tibial tuberosity (a bone on the right knee), and psychoactive (a medication that changes brain function) substance dependence of methadone. Resident 76's history and physical indicated the resident had the capacity to make health care decisions. Resident 76's electronic medication administration record (eMAR) for the month of August 2018, indicated: - "...methadone...10 mg (milligram - a unit of measurement)...1 tablet; oral...Twice A Day...chronic pain management... Reasons/Comments: Not Administered: Drug/Item unavailable: 08/09/2018, 9:00 AM...08/15/2018, 5:00 PM...08/17/2018, 9:00 AM... 8/17/2018, 5:00 PM..." Resident 76's eMAR for the month of September 2018, indicated: - "...methadone tablet; 10 mg...0.5 tablet; oral...At Bedtime...for pain management... Reasons/Comments: Not Administered: Drug/Item unavailable: 09/07/2018, 9:00 PM...09/08/2018, 9:00 PM...09/09/2018, 9:00 PM...and 09/10/2018, 9:00 PM..." In a concurrent interview MDS/LVN 2 acknowledged methadone was not administered to Resident 76 on multiple occasions because the drug was unavailable. MDS/LVN 2 stated there was no documented FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 38 of 140 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 10/01/2018 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 evidence Resident 76's pain assessments were conducted when the methadone was not administered to the resident on those dates. MDS/LVN 2 stated there was no documented evidence the physician was informed of the missed doses of methadone for Resident 76. On October 1, 2018, at 10:46 a.m., Resident 76 was observed awake, alert, and lying in bed. In a concurrent interview, Resident 76 stated, he was told by the nurses when his methadone was unavailable but he could not recall the exact dates when it was. Resident 76 stated he needed the methadone to control his chronic pain. Resident 76 further stated he felt "terrible pain" whenever methadone was not administered to him. 7. On September 28, 2018, at 11:03 a.m., Resident 9's record was reviewed with Minimum Data Set (MDS - an assessment tool) / Licensed Vocational Nurse (LVN) 2. Resident 9 was admitted to the facility on August 29, 2017, with diagnoses that included peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to the limbs), and radiculopathy (a pinched nerve causing pain). Resident 9's history and physical indicated she had the capacity to understand and make health care decisions. Resident 9's electronic medication administration record (eMAR) for the month of September 2018, indicated: - "...Lyrica (pregabalin) capsule; 75 mg...1 capsule; oral...Twice A Day...neuropathy... FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 39 of 140 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 10/01/2018 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 Reasons/Comments: Not Administered: Drug/Item Unavailable: 09/13/2018, 9:00 AM...09/13/2018, 5:00 PM...09/14/2018, 9:00 AM..." In a concurrent interview MDS/LVN 2 acknowledged lyrica was not administered to Resident 9 on multiple occasions because the drug was unavailable. MDS/LVN 2 stated there was no documented evidence Resident 9's pain assessments were conducted when the lyrica was not administered to the resident on those dates. MDS/LVN 2 stated there was no documented evidence the physician was informed of the missed doses of lyrica for Resident 9. On October 1, 2018, at 10:52 a.m., Resident 9 was observed sitting on her wheelchair inside her room. In a concurrent interview, Resident 9 stated she was made aware by the nurse on multiple occasions that lyrica was unavailable, but could not recall the exact dates when it was. Resident 9 stated she felt "terrible" when she missed her lyrica medication. Resident 9 further stated she felt as if there was a "tight band-aid" around her fingers, and her fingers were numb, and felt like "more than a tingling sensation." 8. On September 28, 2018, at 10:41 a.m., Resident 28's record was reviewed with Minimum Data Set (MDS - an assessment tool) / Licensed Vocational Nurse (LVN) 2. Resident 28 was admitted to the facility on June 29, 2018, with diagnoses that included unspecified pain, and malignant neoplasm of the colon FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 40 of 140 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 10/01/2018 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 (cancer of the large intestine). Resident 28's history and physical indicated he had the capacity to understand and make medical decisions. Resident 28's electronic medicaion administration record (eMAR) for the month of August 2018, indicated: - "...tramadol...tablet; 50 mg...50 MG; oral...Every 4 Hours...PAIN MANAGEMENT... Reasons/Comments: Not Administered: Drug/Item unavailable: 08/04/2018, 6:00 AM...08/04/2018, 10:00 AM...and 08/04/2018, 2:00 PM..." Resident 28's eMAR for the month of September 2018, indicated: - "...tramadol...tablet; 50 mg...50 MG; oral...Every 4 Hours...PAIN MANAGEMENT... Reasons/Comments: Not Administered: Drug/Item unavailable: 09/04/2018, 10:00 AM..." In a concurrent interview, MDS/LVN 2 acknowledged tramadol was not administered on multiple occasions because the drug was unavailable. MDS/LVN 2 stated there was no documented evidence Resident 28's pain assessment was conducted when tramadol medications were not administered to the resident on those dates. LVN/MDSN stated there was no documented evidence the physician was informed of the missed doses of tramadol for Resident 28. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 41 of 140 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 10/01/2018 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 On October 1, 2018, at 10:39 a.m., Resident 28 was observed awake and alert, and lying in bed. In a concurrent interview, Resident 28 stated he was made aware by the nurse on multiple occasions that tramadol was unavailable, but could not recall the exact dates when it was. Resident 28 further stated when he missed his tramadol medication, he felt "terrible pain" from his legs all the way up to his body. 9. On September 28, 2018, at 10:58 a.m., Resident 56's record was reviewed with Minimum Data Set (MDS - an assessment tool) / Licensed Vocational Nurse (LVN) 2. Resident 56 was admitted to the facility on June 17, 2018, with diagnoses that included non-healing wounds of both lower extremities, pain in right shoulder, and dorsalgia (low-back pain). Resident 56's history and physical indicated she had the capacity to understand and make health care decisions. Resdient 56's electronic medication administration record (eMAR) for the month of August 2018, indicated: - "...fentanyl...patch 72 hour; 12 mcg/hr (microgram per hour- a unit of measurement)...1 patch; transdermal...Every 72 Hours...for pain control... Reasons/Comments: Not Administered: Drug/Item Unavailable: August 4, 2018, 9:00 AM...and 8/16/2018, 9:00 AM..." In a concurrent interview, MDS/LVN 2 acknowledged fentanyl patch was not administered on multiple occasions because the drug was unavailable. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 42 of 140 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 10/01/2018 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 MDS/LVN 2 stated there was no documented evidence Resident 56's pain assessments were conducted when fentanyl patch were not administered on those dates. LVN/MDSN stated there was no documented evidence the physician was informed of the missed doses of fentanly patch for Resident 56. On October 1, 2018, at 10:41 a.m., Resident 56 was observed awake and alert, while sitting at the side of her bed, rubbing her legs with her hands. In a concurrent interview, Resident 56 stated she currently had severe pain on both lower legs and she just took her pain medication. Resident 56 stated the nurse had informed her on multiple occasions when her fentanyl patch was unavailable. Resident 56 further stated she felt "terrible pain' when fentanyl patch was not given to her. 10. On September 28, 2018, Resident 57's record was reviewed. Resident 57 was admitted to the facility on April 14, 2018, with diagnoses that included benign prostatic hyperplasia (BPH - enlarged prostate gland that can cause uncomfortable urinary symptoms, such as blocking the flow of urine out of the bladder...cause bladder, urinary tract or kidney problems with lower urinary tract infection [UTI]). The physician's order dated August 9, 2018, indicated, "Bactrim...400-800 mg (milligram)...1 tablet Once A Day Every Other Day for prophylaxis (action taken to prevent disease)..." The Medication Administration Record (MAR) for September 2018, indicated Bactrim 400-800 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 43 of 140 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 10/01/2018 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 mg was documented not available and not administered on September 2, 4, 10, and 12, 2018. On September 28, 2018, at 9:33 a.m., Registered Nurse (RN) 1 was interviewed. RN 1 verified Bactrim was not administered to Resident 57 on September 2, 4, 10, and 12, 2018, because it was not available. RN 1 stated the Bactrim was in the OMNIcell (ADDS - automatic drug dispenser system). RN 1 further stated Bactrim should have taken out from the OMNIcell and should have been administered to Resident 57 on September 2, 4, 10, and 12, 2018. In addition, RN 1 stated the physician should have been called and informed the Bactrim was not administered as ordered on September 2, 4, 10, and 12, 2018. RN 1 stated Resident 57 had recurrent history of UTI's. RN 1 further stated it is a physician's order that had to be followed to prevent worsening of UTI into sepsis (generalized spread of infection in the body). 11. On September 28, 2018, Resident 197's record was reviewed. Resident 197 was admitted to the facility on September 21, 2018, with diagnoses that included glaucoma. The physician's order dated September 21, 2018, indicated: - "Travatan Z...drops; 0.04 % (percent); amt (amount): 1 drop per eye...At Bedtime..."; and - "Xalatan...drops; 0.005 %; amt: 1 drop per eye...At Bedtime..." Resident 197's electronic Medication FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 44 of 140 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 10/01/2018 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 Administration Record (eMAR) for September 2018, indicated Travatan and Xalatan were not available and were not administered on September 22, 2018. On September 28, 2018, at 10:22 a.m., the Registered Nurse (RN) and Minimum Data Set (MDS - an assessment tool) / Licensed Vocational Nurse (LVN) was interviewed. RN 1 stated medications for newly admitted residents were usually available on the same day or the next day for the first dose administration. RN 1 stated the physician should have been informed the eyedrop medications fro Resident 197 were not available and not administered as ordered on September 22, 2018. MDS/LVN 2 stated, Resident 197 was up and about and need his eye medication to maintain adequate vision and function especially when performing activities of daily living (ADL). On October 1, 2018, at 10:00 a.m., Resident 197 was interviewed. Resident 197 stated his right eye had no vision and the left eye gets blurry if he missed his eye medications. Resident 197 further stated, it affects how he see things and and how he functions. 12. On September 17, 2018, Resident 90's record was reviewed. Resident 90 was admitted to the facility on November 1, 2016, with diagnoses that included unspecified pain and history of fracture (break in the bone) on the right femur (thighbone). The care plan dated November 30, 2017, indicated, "Problem...Resident expressed alteration in Comfort and Daily Activity due to presence of pain...Approach...Administer pain medication as ordered...Gabapentin (nerve pain medication) 400 mg (milligrams) PO (by mouth) Q (every) 8 hours..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 45 of 140 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 10/01/2018 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 August 2018 electronic Medication Administration Record (eMAR) indicated Resident 90 had a physician's order, with a start date of June 1, 2018, for gabapentin capsule 400 one capsule to be given by mouth every eight hours for neuropathy. Further review of the August 2018 eMAR indicated, the gabapentin 400 mg was not administered to Resident 90 due to medication unavailability on the following dates: - August 1, 2018, at 6 a.m.; - August 2, 2018, at 6 a.m.; - August 3, 2018, at 6 a.m.; - August 5, 2018, at 6 a.m.; - August 6, 2018, at 6 a.m.; and - August 9, 2018 at 6 a.m. There was no documented evidence the licensed nurse had notified the physician on Resident 90's missed doses of gabapentin on those dates. In addition, there was no documented evidence the licensed nurse had monitored the resident on the possible side effects of the missed doses. On October 1, 2018, at 8:47 a.m., Resident 90's record was reviewed with Licensed Vocational Nurse (LVN) 6. LVN 6 verified her electronic signatures for the missed doses of gabapentin. LVN 6 stated she was not able to administer the gabapentin because the medication was not available on August 1, 2, 3, 5, 6, and 9, 2018. LVN 6 further stated she did not notify Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 46 of 140 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 10/01/2018 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 90's physician on the missed doses of gabapentin on those dates. LVN 6 stated she did not assess the resident for pain when the medication was not given. LVN 6 further stated Resident 90 would be in pain if she missed a dose of her gabapentin. LVN 6 stated she did not notify the pharmacy on the medication unavailability. LVN 6 stated she should have notified Resident 90's physician on the missed doses of Gabapentin and assessed the resident for pain due to the missed doses of Gabapentin. 13. On September 26, 2018, Resident 43's record was reviewed. Resident 46 was admitted to the facility on April 16, 2018, with diagnoses that included multiple sclerosis (disease in which the immune system eats away at the protective covering of the nerves) and open wound to right thigh sequela (condition that is the consequence of a previous disease or injury) The physician's order dated September 3, 2017, indicated, "morphine...tablet extended release...15 mg (milligrams)...1 tablet oral...every 12 hours...for pain management..." The Nursing Pain Evaluation Assessment dated July 30, 2018, indicated Resident 43 was at risk for pain related to her diagnosis of multiple sclerosis The care plan dated August 2, 2018, indicated, "Problem...Resident expressed alteration in Comfort and Daily Activity due to presence of pain...as caused by...wound...contractures...Spasm...Multiple Sclerosis...Approach...Administer pain medication as ordered...Morphine 15 mg PO q FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 47 of 140 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 10/01/2018 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 (every) 12h (hours)..." The August 2018 electronic Medication Administration Record (eMAR) indicated the licensed nurse was not able to administer the Morphine 15 mg tablet for pain due to medication unavailability on the following dates: - August 6, 2018, at 9 p.m.; - August 7, 2018, at 9 a.m. and 9 p.m.; - August 8, 2018, at 9 a.m. and 9 p.m.; - August 8, 2018, at 9 p.m.; and - August 23, 2018 at 9 p.m. The September 2018 eMAR indicated the licensed nurse was not able to administer the Morphine 15 mg tablet for pain due to medication unavailability on the following dates: - September 8, 2018, at 9 a.m.; - September 14, 2018, at 9 a.m. and 9 p.m.; - September 15, 2018, at 9 a.m.; - September 16, 2018, at 9 a.m. and 9 p.m.; - September 17, 2018, at 9 a.m.; - September 18, 2018, at 9 a.m.; - September 19, 2018, at 9 a.m.; - September20, 2018, at 9 a.m. and 9 p.m.; and - September 21, 2018, at 9 a.m. and 9 p.m. There was no documented evidence Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 48 of 140 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 10/01/2018 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 43 was assessed and monitored for pain when the medication Morphine was not administered due to medication unavailability in August 2018 and September 2018. On October 1, 2018, at 10:36 a.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN) 3. LVN 3 stated he was not able to administer the 9 a.m. dose of the Morphine tablet to Resident 43 on September 8, 14, 15, 16, 17, 18, and 21, 2018, because it was unavailable. LVN 3 stated Resident 43 would be experiencing pain if the medication Morphine was not administered. LVN 3 further stated he did not assess Resident 43's pain when the Morphine was not given on those dates. LVN 3 stated he did not have documented evidence the physician was notified when the morphine was not administered to Resident 43 on those dates. LVN 3 stated he should have assessed and monitored Resident 43 for the possible side effects from missing the dose of morphine on multiple occasions. 14. On September 24, 2018, at 3:06 p.m., an observation and an interview was conducted on Resident 42. Resident 42 was sitting in his motorized wheelchair. Resident 42 was wearing a sock on his right foot, and a shoe on his left foot. Resident 42's right foot was observed to be swollen from ankle down. Resident 42's right foot had a cloth velcro and was strapped to the right side of the bar close to his wheelchair foot rest. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 49 of 140 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 10/01/2018 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 Resident 42's feet were flaccid (loose and floppy) and did not have any form of device or cushion on the wheelchair foot rest for the resident's foot support. Resident 42 stated the swelling on his right foot started a couple of weeks ago. Resident 42 stated he was not able to wear a shoe on his right foot because it was swollen. Resident 42 stated he stayed sitted in his wheelchair most of the time during the day. Resident 42 stated he did not have movement or feeling from waist down, so he was not able to move his feet. On September 25, 2018, at 10:30 a.m., Resident 42's record was reviewed with Registered Nurse (RN) 2. Resident 42 was readmitted to the facility on June 12, 2018, with diagnoses that included quadriplegia (type of paralysis caused by illness or injury that results in partial or total loss of use on all four limbs and torso); and disorder of kidney and ureter. The nursing progress notes dated September 4, 2018, indicated the licensed nurse identified a + 3 pitting edema on Resident 42's right foot. Further review of Resident 42's nursing progress notes indicated, Resident 42 was monitored for the complications of the edema to his right foot from September 4 to September 6, 2018. There were no documented evidence regarding the status of Resident 42's right foot edema after September 6, 2018. In addition, there was no documented evidence the facility had provided measures and interventions to prevent further complications on Resident 42's right foot edema nor Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 50 of 140 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 10/01/2018 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 42's right foor edema was identified by the facility as an ongoing medical issue. In a concurrent interview, RN 2 stated there was no documented evidence of a current plan of treatment for Resident 42's right foot edema. RN 2 stated the licensed nurse who had identified the edema on Spetember 4, 2018, should have initiated a care plan to address the edema. RN 2 further stated Resident 42's edema should have been evaluated by the licensed nurses after the monitoring was completed on September 6, 2018. RN 2 stated the nurses should have notified the physician on Resident 42's current edema of the right foot. RN 2 stated the Certified Nursing Assistants (CNAs) should have elevated the affected foot, and the licensed nurses should have monitored the resident for changes or complications related to his edema. 15. On September 24, 2018, at 3:06 p.m., an observation and an interview was conducted on Resident 42. Resident 42 was sitting in his motorized wheelchair. Resident 42 was wearing a sock on his right foot, and a shoe on his left foot. Resident 42's right foot was observed to be swollen from ankle down. Resident 42's right foot had a cloth velcro and was strapped to the right side of the bar close to his wheelchair foot rest. Resident 42's feet were flaccid (loose and floppy) and did not have any form of device or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 51 of 140 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 10/01/2018 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 cushion on the wheelchair foot rest for the resident's foot support. Resident 42 stated the swelling on his right foot started a couple of weeks ago. Resident 42 stated he was not able to wear a shoe on his right foot because it was swollen. Resident 42 stated he stayed sitted in his wheelchair most of the time during the day. Resident 42 stated he did not have movement or feeling from waist down, so he was not able to move his feet. Resident 42 stated he had asked the CNA to strap his right foot to the bar near the right side of his footrest, for positioning. Resident 42 stated he used the velcro strap to secure his right foot so it would not move about when he is up in his wheelchair. On September 25, 2018, at 10:30 a.m., Resident 42 was observed in his wheelchair on the hallway. Resident's feet were both strapped together with the velcro strap. Resident 42's wheelchair foot rest did not have any form of device or cushion to support the resident's feet. On September 25, 2018, at 11:15 a.m., Resident 42's record was reviewed with Minimum Data Set (MDS - an assessment tool) / Licensed Vocational Nurrse (LVN) 2. Resident 42 was re-admitted to the facility on June 12, 2018, with diagnoses that included quadriplegia (type of paralysis caused by illness or injury that results in partial or total loss of use on all four limbs and torso). There was no documented evidence Resident 42 was assessed for the use of a velcro strap as a positioning device for his lower extremities. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 52 of 140 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 10/01/2018 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 In a concurrent interview, MDS/LVN 2 stated the rehabilitation department were responsible for determining the appropriate positioning device the resident needed. MDS/LVN 2 stated Resident 42 did not have a care plan on the use of velcro straps as a positining device. In addition, MDS/LVN 2 stated there was no documented evidence the facility had identified Resident 42's practice to use the velcro strap as a positioning device for his lower extremities MDS/LVN 2 stated the velcro strap was inappropriate to use as a positioning device for Resident 42. MDS/LVN 2 stated Resident 42 should have been assessed for the appropriate positioning device to use for his lower extremities. MDS/LVN 2 stated Resident 42 was not able to move and feel his lower extremities due to quadreplegia and using an inappropriate positioning device would put the resident at risk for skin breakdown and other complications. The facility's policy and procedure titled, "Assistive Equipment and Devices," dated July 6, 2018, was reviewed. The policy indicated, "...Recommendations for the use of devices and equipment are based on the comprhensive assessment and documented in the resident's plan of care... The following factors will be addressed to the extent possible to decrease the risk of avoidable accidents associated with devices and equipments... Appropriateness for resident condition - the resident will be assessed for lower extremity strength, range of motion, balance and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 53 of 140 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 10/01/2018 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 cognitive abilities when determining the safest use of devices and equipment..."

F755 SS=H Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 10/28/2018 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 54 of 140 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 10/01/2018 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 reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure 25 of 91 residents reviewed (Residents 44, 74, 61, 17, 9, 56, 28, 76, 77, 395, 47, 90, 43, 57, 197, 192, 25, 199, 69, 53, 194, 196, 198, 195, and 36) prescribed medications were provided and available for timely administration from the period of August to September 2018. This failure resulted for the residents not receiving the medications as ordered by the physician to manage and treat medical conditions, and overall long-term health and well-being of the residents. Findings: 1. On September 25, 2018, Resident 44's record was reviewed. Resident 44 was readmitted to the facility on January 8, 2018, with diagnoses that included myalgia (muscle pain), lumbago (low back pain), and chronic pain syndrome. Resident 44 had cognitive decision-making. Resident 44 physician's order indicated, "...fentanyl (narcotic pain medication)...patch 72 hour; 12 mcg/hr (microgram/hour)...apply 1 patch transdermal (application of a medication through the skin)...Every 72 Hours; 09:00 AM..." date ordered February 3, 2018. Resident 44's electronic Medication Administration Record (eMAR) for the month of September 2018, indicated Resident 44's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 55 of 140 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 10/01/2018 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 fentanyl patch was not given to the resident from September 10 to September 15, 2018. Further review of Resident 44's eMAR for September 2018, indicated the following: - "...Monitor FENTANYL patch placement Qshift... - 09/10/2018 03:56 PM...waiting on pharmacy to deliver... - 09/12/2018 03:01 PM...PHARMACY WILL FAX (name of doctor) for continuous (sic)... - 09/12/2018 05:18 PM Not Administered: On Hold - 09/13/2018 02:10 AM Not Administered: On Hold - 09/13/2018 01:42 PM Not Administered: On Hold - 09/13/2018 04:20 PM Not Administered: Drug/Item unavailable - 09/14/2018 01:09 AM Not Administered: Drug/Item unavailable - 09/15/2018 11:38 AM Not Administered...off..." Resident 44's fentanyl patch narcotic count sheet, with a delivery date of the medication on August 10, 2018, indicated 10 patch was delivered. The fenatanyl narcotic count sheet indicated the 10th patch was used on September 7, 2018. Resident 44's fentanyl patch narcotic count sheet, with a delivery date of the medication on September 15, 2018, indicated 5 patch was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 56 of 140 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 10/01/2018 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 delivered. The fentanyl narcotic count sheet indicated the first patch was used on September 16, 2018. On September 25, 2018, at 11:50 a.m., Resident 44 was interviewed. Resident 44 stated she was always in pain because of her myalgia. Resident 44 stated her pain medication was important for her to have so she could manage her pain. Resident 44 stated she used the fentanyl patch for her myalgia pain. Resident 44 stated the fentanyl patch would not completely remove her pain but the medication helped bring down her pain on a tolerable level. Resident 44 stated she had several days in the month of September 2018 where she did not have the fentanyl patch. Resident 44 stated the nurses told her the fentanyl patch was not available because the pharmacy was waiting for the physician's authorization. Resident 44 stated her pain level on the days she did not have the fentanyl patch were 8/10 (pain rating scale 0 to 10: 8-10 severe pain). Resident 44 stated because of severe pain she mostly stayed in bed. Resident 44 further stated, "I sleep it off...so not to feel the pain." On September 28, 2018, at 1:05 p.m., Licensed Vocational Nurse (LVN) 5 was interviewed. LVN 5 stated she was the nurse assigned to Resident 44 on September 13, 2018. LVN 5 stated Resident 44 was scheduled to receive a fentanyl patch on that day, but the medication was not available. LVN 5 stated Resident 44 needed her fentanyl patch for pain management. LVN 5 stated the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 57 of 140 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 10/01/2018 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 fentanyl patch was not available because the pharmacy was waiting for the physician's authorization. LVN 5 stated she did not followed up with the pharmacy for the status of fentanyl patch refill. LVN 5 stated she did not notified the physician when Resident 44's fentanyl patch was not available. LVN 5 stated she did not have documented evidence of Resident 44's pain assessment on September 13, 2018, when she was the assigned nurse. LVN 5 stated she should have coordinated with the pharmacy in obtaining the physician's authorization for fentanyl patch order. LVN 5 stated she should have notified the physician when Resident 44's fentanyl patch was not available. LVN 5 stated she should have asked the physician for alternative pain medication for Resident 44 when fentanyl patch was not available. On October 1, 2018, at 5:38 p.m., a concurrent record review and interview was conducted with the Minimum Data Set (MDS- an assessment tool)/ Licensed Vocational Nurse (LVN) 2. MDS/LVN 2 verified the fentanyl patch was not given to Resident 44 from September 10 to September 15, 2018, because it was not available. MDS/LVN 2 verified there was no documented evidence Resident 44's pain assessment was conducted on September 10 to 15, 2018. MDS/LVN 2 verified there was no documented evidence the physician was notified of the fentanyl patch not administered to Resident 44 because it was not available. MDS/LVN 2 further stated residents' FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 58 of 140 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 10/01/2018 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 medication refills should be requested five days before the last dose to ensure pharmacy would deliver it before the medication run out. MDS/LVN 2 stated for controlled medication refill (such as fentanyl patch) the nurses should have communicated with the pharmacy for the status of the request. The nurses should have informed the DON or the Administrator if there was a delay with the physician authorization to help expedite in obtaining authorization for the controlled medication. On September 25, 2018, at 3:15 p.m., the Director of Nursing (DON) was interviewed. The DON stated she was not aware the fentanyl patch for Resident 44 was not available because the pharmacy was waiting for the physician's authorization. The DON stated the nurses should have notified the physician when fentanyl was not available. The DON stated the nurses should have asked the physician for alternative pain medication while fentanyl patch was not available for Resident 44. The DON stated it is not acceptable for Resident 44 not to have the fentanyl patch nor an alternative pain medication for several days. 2. On September 24, 2018, at 9:35 a.m. a medication pass observation on Resident 74 was conducted with Licensed Vocational Nurse (LVN) 4. LVN 4 was observed verifying medications with the physician's orders in the electronic Medication Administration Record (eMAR) as she prepared the following medications in the medication cup: - One tablet of aspirin (prophylaxis for stroke); - One tablet of atenolol (medication used for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 59 of 140 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 10/01/2018 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 high blood pressure - that is 140/90 or higher); and - One tablet of diltiazem (medication used for high blood pressure). On September 24, 2018, at 9:50 a.m., LVN 4 administered these medications to Resident 74 then subsequently signed the eMAR. On September 24, 2018, at 12:30 p.m., Resident 74's record was reviewed. Resident 74 was admitted to the facility on February 8, 2017, with diagnoses that included hypertension (high blood pressure). Resident 74's physician's order indicated the following medications were scheduled to be administered at 9 a.m.: - "...aspirin...81 mg (milligram)...1 tablet; oral...Once A day; 09:00 AM..." date ordered June 29, 2017; - "...atenolol...50 mg...1 tablet; oral...Once A Day; 09:00 AM..." date ordered May 31, 2018; - "...Lasix (diuretic medication)...20 mg...1 tablet; oral...for HTN (hypertension)...Once A Day; 09:00 AM..." date ordered May 31, 2018; and - "...diltiazem...60 mg...oral...Once A day; 09:00 AM..." date ordered July 23, 2018. On September 24, 2018, at 4:10 p.m., a concurrent record review and interview was conducted with LVN 4. LVN 4 verified Resident 74's lasix was administered to the resident at 9 a.m. LVN 4 was made aware the Lasix medication was not observed to have prepared and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 60 of 140 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 10/01/2018 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 administered to Resident 74. LVN 4 stated she will check the Lasix medication pack to verify the medication was administered today. After checking her medication cart, LVN 4 stated Resident 74 did not have a medication pack for Lasix. LVN 4 stated Resident 74's Lasix was not available to be administered. LVN 4 stated she made a mistake in signing the eMAR for 9 a.m. dose today as administered. LVN 4 stated she did not give Resident 74's lasix today because it was not available. 3. On September 24, 2018, at 9:19 a.m. a medication pass observation on Resident 61 was conducted with Licensed Vocational Nurse (LVN) 4. LVN 4 was observed verifying medications with the physician's orders in the electronic Medication Administration Record (eMAR) as she prepared the following medications in the medication cup: - One tablet of vitamin C (supplement); - One capsule of cranberry extract (supplement used to prevent urinary tract infection); - One tablet of Furosemide (a diuretic medication); - Two capsule of milk thistle (supplement used to treat liver problem); - One tablet of Klor-Con (potassium chloride an electrolyte supplement) - One tablet of sodium chloride (an electrolyte supplement); and - One capsule of zinc sulfate (supplement). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 61 of 140 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 10/01/2018 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 LVN 4 stated Resident 61 refused the 9 a.m. dose of his antihypertensive medication (for high blood pressure - that is 140/90 or higher). On September 24, 2018, at 9:30 a.m., LVN 4 administered these medications to Resident 61 then subsequently signed the eMAR. On September 24, 2018, at 12 p.m., Resident 61's record was reviewed. Resident 61 was readmitted to the facility on May 21, 2018, with diagnoses that included liver cirrhosis (a liver disease), urinary tract infection, and benign prostatic hyperplasia (BPH - enlargement of the prostate gland). Resident 61's physician's order indicated the following medications were scheduled to be administered at 9 a.m.: - "...vitamin C...tablet; 500 mg (milligram)...1 tab (tablet); oral...Once A day; 09:00 AM..." date ordered May 21, 2018; - " ...cranberry...400 mg...1 capsule; oral...Once A Day; 09:00 AM..." date ordered May 21, 2018; - "...sodium chloride...1 gram...1 tab; oral...Twice A Day; 09:00 AM..." date ordered May 21, 2018; - "...furosemide...20 mg...1 tab; oral...scrotal swelling Once A Day; 09:00 AM..." date ordered May 22, 2018; - "...potassium chloride...10 mEq (milliequivalent)...1 tab; oral...supplement Once A Day; 09:00 AM..." date ordered May 22, 2018; - "...Valtrex (antiviral medication)...500 mg; 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 62 of 140 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 10/01/2018 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 tab; oral...PPx (prophylaxis) for Viral Rash Once A Day; 09:00 AM..." date ordered September 20, 2018; - "...zinc sulfate...220 (50) mg...1 capsule; oral...Once A Day; 09:00 AM..." dated May 22, 2018; - "...lactulose solution (medication for treating liver disease); 20 gram/30 ml (milliliter)...45ml (30g total); oral...Cirrhosis Twice A Day; 09:00 AM..." dated May 23, 2018; - "...carvedilol tablet (medication used for high blood pressure); 6.25 mg...oral...for HTN (hypertension - high blood pressure)...Twice A Day; 09:00 AM..." dated May 25, 2018; and - "...tamsulosin (medication for BPH)...0.4 mg...1 tab; oral...Once A Day; 09:00 AM..." dated May 31, 2018. On September 24, 2018, at 4:04 p.m., a concurrent record review and interview was conducted with LVN 4. LVN 4 verified Resident 61's medications: lactulose, tamsulosin, and valtrex were scheduled to be given at 9 a.m. LVN 4 was made aware on the following medications not observed to have prepared and administered to Resident 61: - Lactulose; - Tamsulosin; and - Valtrex. LVN 4 stated the Lactulose was given to Resident 61 at 8:00 a.m., as requested by the resident. LVN 4 stated the Tamsulosin and Valtrex were not administered to Resident 61 because it was not available. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 63 of 140 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 10/01/2018 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 LVN 4 stated when medications were not available, medication refill should have been requested and a follow up call should be have been made to the pharmacy for the time of delivery. LVN 4 stated the physician should have been notified of medications not administered to the residents. LVN 4 stated the residents' medication refill should be requested from the pharmacy five days before the last dose. LVN 4 stated it is important for the refill request submitted ahead of time to ensure the resident's medication would be available for administration. LVN 4 stated the refill of the missing medications were not yet delivered. LVN 1 stated she did not follow up with the pharmacy for the status of the refill requests. LVN 4 further stated she did not notify the physician on Resident 61's medications: tamsulosin and valtrex, were not given because it was unavailable. 4. On September 27, 2018, Resident 17's record was reviewed. Resident 17 was admitted to the facility on December 16, 2016, with diagnoses that included unspecified pain. Resident 17's electronic Medication Administration Record (eMAR) for the month of September 2018, was reviewed . The physician's orders in the eMAR indicated Methadone tablet 5 mg (milligrams) to administer 0.5 mg tablet by mouth every 12 hours for pain management with the goal of "pain level of 0-2/10 (0-2 in a scale of 0-10 being 10 the worst pain)." Further review of Resident 17's eMAR indicated, the resident did not receive his Methadone dose on the following dates: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 64 of 140 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 10/01/2018 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 - September 15, 16, and 18, 2018 at 9 a.m. and 9 p.m. ; and - September 19, 2018 the dose at 9 a.m. On September 27, 2018 at 10 a.m., an interview was conducted with Licensed Vocational Nurse (LVN) 2. LVN 2 stated when medications are not available, the licensed nurse should call the pharmacy and asks when the facility is going to receive the medication. LVN 2 further stated she follows up with pharmacy usually after rounds and calls the pharmacy again at the end of the shift. On September 28, 2018, at 11:20 a.m., a concurrent interview and record review was conducted with LVN 3. LVN 3 verified the Methadone doses were not administered to Resident 17 on September 15, 16, 18, and 19, 2018. 5. On September 28, 2018, at 11:03 a.m., Resident 9's record was reviewed with Minimum Data Set (MDS - an assessment tool) / Licensed Vocational Nurse (LVN) 2. Resident 9 was admitted to the facility on August 29, 2017, with diagnoses that included peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to the limbs), and radiculopathy (a pinched nerve causing pain). Resident 9's electronic medication administration record (eMAR) for the month of September 2018, indicated: - "...Lyrica (pregabalin) capsule; 75 mg...1 capsule; oral...Twice A Day...neuropathy... Reasons/Comments: Not Administered: Drug/Item Unavailable: 09/13/2018, 9:00 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 65 of 140 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 10/01/2018 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 AM...09/13/2018, 5:00 PM...09/14/2018, 9:00 AM..." In a concurrent interview MDS/LVN 2 acknowledged lyrica was not administered to Resident 9 on multiple occasions because the drug was unavailable. MDS/LVN 2 stated there was no documented evidence the physician was informed of the missed doses of lyrica for Resident 9. On October 1, 2018, at 10:52 a.m., Resident 9 was observed sitting on her wheelchair inside her room. In a concurrent interview, Resident 9 stated she was made aware by the nurse on multiple occasions that lyrica was unavailable, but could not recall the exact dates when it was. 6. On September 28, 2018, at 10:58 a.m., Resident 56's record was reviewed with Minimum Data Set (MDS - an assessment tool) / Licensed Vocational Nurse (LVN) 2. Resident 56 was admitted to the facility on June 17, 2018, with diagnoses that included non-healing wounds of both lower extremities, pain in right shoulder, and dorsalgia (low-back pain). Resdient 56's electronic medication administration record (eMAR) for the month of August 2018, indicated: - "...fentanyl...patch 72 hour; 12 mcg/hr (microgram per hour- a unit of measurement)...1 patch; transdermal...Every 72 Hours...for pain control... Reasons/Comments: Not Administered: Drug/Item Unavailable: August 4, 2018, 9:00 AM...and 8/16/2018, 9:00 AM..." In a concurrent interview, MDS/LVN 2 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 66 of 140 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 10/01/2018 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 acknowledged fentanyl patch was not administered on multiple occasions because the drug was unavailable. LVN/MDSN 2 stated there was no documented evidence the physician was informed of the missed doses of fentanly patch for Resident 56. On October 1, 2018, at 10:41 a.m., Resident 56 was observed awake and alert, while sitting at the side of her bed, rubbing her legs with her hands. In a concurrent interview, Resident 56 stated she currently had severe pain on both lower legs and she just took her pain medication. Resident 56 stated the nurse had informed her on multiple occasions when her fentanyl patch was unavailable. Resident 56 further stated she felt "terrible pain' when fentanyl patch was not given to her. 7. On September 28, 2018, at 10:41 a.m., Resident 28's record was reviewed with Minimum Data Set (MDS - an assessment tool) / Licensed Vocational Nurse (LVN) 2. Resident 28 was admitted to the facility on June 29, 2018, with diagnoses that included unspecified pain, and malignant neoplasm of the colon (cancer of the large intestine). Resident 28's electronic medication administration record (eMAR) for the month of August 2018, indicated: - "...tramadol...tablet; 50 mg...50 MG; oral...Every 4 Hours...PAIN MANAGEMENT... Reasons/Comments: Not Administered: Drug/Item unavailable: 08/04/2018, 6:00 AM...08/04/2018, 10:00 AM...and 08/04/2018, 2:00 PM..." Resident 28's eMAR for the month of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 67 of 140 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 10/01/2018 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 September 2018, indicated: - "...tramadol...tablet; 50 mg...50 MG; oral...Every 4 Hours...PAIN MANAGEMENT... Reasons/Comments: Not Administered: Drug/Item unavailable: 09/04/2018, 10:00 AM..." In a concurrent interview, MDS/LVN 2 acknowledged tramadol was not administered on multiple occasions because the drug was unavailable. LVN/MDSN 2 stated there was no documented evidence the physician was informed of the missed doses of tramadol for Resident 28. On October 1, 2018, at 10:39 a.m., Resident 28 was observed awake and alert, and lying in bed. In a concurrent interview, Resident 28 stated he was made aware by the nurse on multiple occasions that tramadol was unavailable, but could not recall the exact dates when it was. Resident 28 further stated when he missed his tramadol medication, he felt "terrible pain" from his legs all the way up to his body. 8. On September 28, 2018, at 10:33 a.m., Resident 76's record was reviewed with Minimum Data Set (MDS - an assessment tool) / Licensed Vocational Nurse (LVN) 2. Resident 76 was admitted to the facility on August 8, 2018, with diagnoses that included pain in unspecified lower leg, low back pain, fracture of the right tibial tuberosity (a bone on the right knee), and psychoactive (a medication that changes brain function) substance dependence of methadone. Resident 76's electronic medication administration record (eMAR) for the month of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 68 of 140 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 10/01/2018 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 August 2018, indicated: - "...methadone...10 mg (milligram - a unit of measurement)...1 tablet; oral...Twice A Day...chronic pain management... Reasons/Comments: Not Administered: Drug/Item unavailable: 08/09/2018, 9:00 AM...08/15/2018, 5:00 PM...08/17/2018, 9:00 AM... 8/17/2018, 5:00 PM..."; "...Eliquis (apixaban) tablet...5 mg...2 tablets; oral...Every 12 Hours...MI (myocardial infarction- heart attack) prevention; Start/End Date: 08/26/2018 - 08/30/2018; Reasons/Comments: Not Administered: Drug unavailable: 08/26/2018, 9:00 PM"; and - "...diazepam (medication used for anxiety)...2 mg; oral...Every 8 Hours...FOR ANXIETY M/B/ CONSTANTLY CALLING/YELLING FOR HELP..." Reasons/Comments: Not Administered: Drug/Item unavailable; 08/09/2018, 2:00 PM; and 08/09/2018, 10:00 PM." Resident 76's eMAR for the month of September 2018, indicated: - "...methadone tablet; 10 mg...0.5 tablet; oral...At Bedtime...for pain management... Reasons/Comments: Not Administered: Drug/Item unavailable: 09/07/2018, 9:00 PM...09/08/2018, 9:00 PM...09/09/2018, 9:00 PM...and 09/10/2018, 9:00 PM..." In a concurrent interview MDS/LVN 2 acknowledged methadone was not administered to Resident 76 on multiple occasions because the drug was unavailable. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 69 of 140 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 10/01/2018 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 MDS/LVN 2 stated there was no documented evidence the physician was informed of the missed doses of methadone for Resident 76. MDS/LVN 2 stated multiple medications were not administered on several occasions because the drugs were unavailable for the resident. MDS/LVN 2 stated there was no documented evidence the physician was informed of the missed medication administration. LVN/MDSN further stated medications should have been reordered on a timely manner, especially for pain medications. 9. On September 28, 2017, at 10:47 a.m., Resident 77's record was reviewed with Mimimun Data Set (MDS- an assessment tool)/ Licensed Vocational Nurse (LVN) 2. Resident 77 was admitted on August 30, 2018, with diagnoses that included end stage renal disease (kidney failure) and dependence on renal dialysis (the process of removing excess water, solutes, and toxins from the blood). Resident 77's electronic medication administration record (eMAR) for the month of August 2018, indicated: - "...lanthanum tablet...1,000 mg...1 TAB (tablet); oral...Three Times A Day...ESRD (endstage renal disease- kidney failure)... Reasons/Comments: Not Administered: Drug/Item Unavailable: 08/31/2018, 9:00 AM; and 08/31/2018, 5:00 PM..." In a concurrent interview, MDS/LVN 2 stated the medication were not administered on several occasions because the drug was unavailable for the resident. MDS/LVN 2 stated there was no documented evidence the physician was informed of the missed medication administration. MDS/LVN 2 further FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 70 of 140 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 10/01/2018 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 stated medications should have been reordered on a timely manner. 10. On September 28, 2017, at 11:07 a.m., Resident 395's record was reviewed with Mimimun Data Set (MDS- an assessment tool)/ Licensed Vocational Nurse (LVN) 2. Resident 395 was admitted on September 1, 2018. Resident 395's eMAR for the month of September 2018, indicated: -"...cetirizine...tablet; 10 mg; Amount to Administer: 1 TAB; oral; Frequency: Once A Day; Special Instructions: FOR: ALLERGY RELIEF; Start/End Date: 09/01/2018 - Open Ended; Reasons/Comments: Not Administered: Drug/Item unavailable: 09/09/2018, 9:00 AM; 09/11/2018, 9:00 AM; and 09/12/2018, 9:00 AM." During a concurrent interview; LVN/MDSN acknowledged the medication was not administered on several occasions because the drug was unavailable for the resident. LVN/MDSN stated there was no documented evidence the physician was informed of the missed medication administration. LVN/MDSN further stated medications should have been reordered on a timely manner. 11. On September 28, 2017, at 11:12 a.m., Resident 47's record was reviewed with Mimimun Data Set (MDS- an assessment tool)/ Licensed Vocational Nurse (LVN) 2. Resident 47 was admitted on April 9, 2018. Resident 47's electronic medication administration record (eMAR) for the month of August 2018, indicated: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 71 of 140 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 10/01/2018 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 - "...pantoprazole tablet...40 mg...oral...Once A Day...GERD (gastro-esophageal reflux disease- acid reflux)... Reasons/Comments: Not Administered: Drug/Item unavailable: 08/24/2018, 6:30 AM; and 08/25/2018, 6:30 AM..." In a concurrent interview, MDS/LVN 2 stated the medication were not administered on several occasions because the drug was unavailable for the resident. MDS/LVN 2 stated there was no documented evidence the physician was informed of the missed medication administration. MDS/LVN 2 further stated medications should have been reordered on a timely manner. 12. On September 17, 2018, Resident 90's record was reviewed. Resident 90 was admitted to the facility on November 1, 2016, with diagnoses that included unspecified pain and history of fracture (break in the bone) on the right femur (thighbone). The August 2018 electronic Administration Record (eMAR) indicated Resident 90 had a physician's order , with a start date of June 1, 2018, for gabapentin capsule 400 one capsule to be given by mouth every eight hours for neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet). The August 2018 eMAR also indicated, the gabapentin 400 mg was not administered to Resident 90 due to medication unavailability on the following dates: - August 1, 2018, at 6 a.m.; - August 2, 2018, at 6 a.m.; - August 3, 2018, at 6 a.m.; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 72 of 140 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 10/01/2018 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 - August 5, 2018, at 6 a.m.; - August 6, 2018, at 6 a.m.; and - August 9, 2018 at 6 a.m. On October 1, 2018, at 8:47 a.m., Resident 90's record was reviewed with Licensed Vocational Nurse (LVN) 5. LVN 5 verified her electronic signatures for the missed doses of gabapentin. LVN 5 stated she was not able to administer the gabapentin because the medication was not available on August 1, 2, 3, 5, 6, and 9, 2018. LVN 5 stated the medication was not in the cart. LVN 1 stated she did not notify the pharmacy on the medication unavailability. 13. On September 26, 2018, Resident 43's record was reviewed. Resident 46 was admitted to the facility on April 16, 2018, with diagnoses that included multiple sclerosis (disease in which the immjune system eats away at the protective covering of the nerves) and open wound to right thigh sequela (condition that is the consequence of a previous disease or injury) The physician's order dated September 3, 2017, indicated, "morphine...tablet extended release...15 mg (milligrams)...1 tablet oral...every 12 hours...for pain management..." The August 2018 electronic Medication Administration Record (eMAR) indicated the licensed nurse was not able to give the Morphine 15 mg tablet for pain due to medication unavailability on the following dates: - August 6, 2018, at 9 p.m.; - August 7, 2018, at 9 a.m. and 9 p.m.; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 73 of 140 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 10/01/2018 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 - August 8, 2018, at 9 a.m. and 9 p.m.; - August 8, 2018, at 9 p.m.; and - August 23, 2018 at 9 p.m. The September 2018 eMAR indicated the licensed nurse was not able to give the Morphine 15 mg tablet for pain due to medication unavailability on the following dates: - September 8, 2018, at 9 a.m.; - September 14, 2018, at 9 a.m. and 9 p.m.; - September 15, 2018, at 9 a.m.; - September 16, 2018, at 9 a.m. and 9 p.m.; - September 17, 2018, at 9 a.m.; - September 18, 2018, at 9 a.m.; - September 19, 2018, at 9 a.m.; - September 20, 2018, at 9 a.m. and 9 p.m.; and - September 21, 2018, at 9 a.m. and 9 p.m. On October 1, 2018, at 10:36 a.m., Resident 43's record was reviewed with Licensed Vocational Nurse (LVN) 3. LVN 3 stated he was not able to administer the 9 a.m. dose of the Morphine tablet to Resident 43 because it was unavailable on September 8, 14, 15, 16, 17, 18, and 21. LVN 3 stated he should have called the pharmacy to follow up on the refill of the Morphine 15 mg. LVN 2 further stated the facility had always encountered issues with the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 74 of 140 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 10/01/2018 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 availability of the medications. 14. On September 28, 2018, Resident 57's record was reviewed. Resident 57 was admitted to the facility on April 14, 2018, with diagnoses that included benign prostatic hyperplasia (BPH - enlarged prostate gland that can cause uncomfortable urinary symptoms, such as blocking the flow of urine out of the bladder...cause bladder, urinary tract or kidney problems with lower urinary tract infection [UTI]). The physician's order dated August 9, 2018, indicated, "Bactrim...400-800 mg (milligram)...1 tablet Once A Day Every Other Day for prophylaxis (action taken to prevent disease)..." The Medication Administration Record (MAR) for September 2018, indicated Bactrim 400-800 mg was documented not available and not administered on September 2, 4, 10, and 12, 2018. On September 28, 2018, at 9:33 a.m., Registered Nurse (RN) 1 was interviewed. RN 1 stated Bactrim was not administered to Resident 57 on September 2, 4, 10, and 12, 2018, because it was not available. In addition, RN 1 stated the physician should have been called and informed the Bactrim was not administered as ordered on September 2, 4, 10, and 12, 2018. 15. On September 28, 2018, Resident 197's record was reviewed. Resident 197 was admitted to the facility on September 21, 2018, with diagnoses that included glaucoma. The physician's order dated September 21, 2018, indicated: - "Travatan Z...drops; 0.04 % (percent); amt (amount): 1 drop per eye...At Bedtime..."; and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 75 of 140 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 10/01/2018 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 - "Xalatan...drops; 0.005 %; amt: 1 drop per eye...At Bedtime..." Resident 197's electronic Medication Administration Record (eMAR) for September 2018, indicated Travatan and Xalatan were not available and were not administered on September 22, 2018. On September 28, 2018, at 10:22 a.m., the Registered Nurse (RN) 1 and Minimum Data Set (MDS - an assessment tool) / Licensed Vocational Nurse (LVN) 2 were interviewed. RN 1 stated medications for newly admitted residents were usually available on the same day or the next day for the first dose administration. RN 1 stated the physician should have been informed the eyedrop medications fro Resident 197 were not available and not administered as ordered on September 22, 2018. MDS/LVN 2 stated, Resident 197 was up and about and need his eye medication to maintain adequate vision and function especially when performing activities of daily living (ADL). 16. On September 28, 2018, Resident 192's record was reviewed. Resident 192 was admitted to the facility on September 15, 2018. The Physician's order included: - "carvedilol tablet; 3.125 mg...Twice A Day...Start...09/15/2018..."; - "benzonatate capsule; 100 mg...Three Times A Day...Start...09/15/2018..." and - "donepezil tablet...5mg...At Bedtime...Start 09/15/2018..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 76 of 140 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 10/01/2018 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 electronic Medication Administration Record (eMAR) for September 2018, indicated medications were not available and not administered to Resident 192 on the following dates: - Carvedilol 3.125 mg on September 15, 2018, at 5:00 p.m.; - Benzonatate 100 mg on September 15, 2018, at 5:00 p.m.; and - Donezepil 15 mg on September 15, 2018, at 9:00 p.m. On September 28, 2018 at 11:00 a.m., the Mimimum Data Set (MDS - resident assessment tool) /Licensed Vocational Nurse (LVN) 2was interviewed. MDS/LVN 2 stated the medications were not administered as ordered. MDS/LVN 2 stated new admission medications should have been ordered, made available, and administered as ordered. 17. On September 28, 2018,Resident 25's record was reviewed. Resident 25 was admitted to the facility on June 24, 2017. The Physician's order included: - "oxycodone-acetaminophen...tablet; 5-325 mg (milligram)...1 TAB (tablet)...Every 12 Hours For Pain...Start...9/16/2017..."; - "Aspir-81 (aspirin) [OTC] (over-the-counter); 81 mg...1tab...Once a Day...Start...6/24/2017..."; - "ferrous sulfate [OTC]...325 mg...Once a Day...Start...9/16/2017..."; and - "Vitamin D3...[OTC] tablet...1000 unit...1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 77 of 140 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 10/01/2018 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 tab...Once a Day...Start...9/16/2017..." The Medication Administration Record (MAR) for August and September 2018, indicated medications were not available and not administered to Resident 25 on the following dates: - oxycodone-acetaminophen 5-325 mg tab on August 4, 2018, at 6:00 a.m.; - Aspir-81 1 tab on September 8, 9, and 10, 2018, at 9:00 a.m.; - ferrous sulfate 325 mg on September 18, 2018, at 9:00 a.m.; and - Vitamin D3 1 tab on September 9 and 10, 2018, at 9:00 a.m. On September 28, 2018 at 11:00 a.m., the Minimum Data Set (MDS - resident assessment tool)/Licensed Vocational Nurse (LVN) 2 was interviewed. MDS/LVN 2 stated the medications were not administered as ordered. MDS/LVN 2 stated the medications should have been ordered/re-ordered, made available, and administered as ordered. MDS/LVN 2 futher stated OTC medications are usually available in the facility and should have been administered as ordered. 18. On September 28, 2018, Resident 199's record was reviewed. Resident 199 was admitted to the facility on September 1, 2018. The Physician's order included, "aspirin [OTC] (over-the-counter) tablet...81 mg...Once a Day...Start...9/1/2018..." The Medication Administration Record (MAR) for September 2018, indicated aspirin FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 78 of 140 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 10/01/2018 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 medication was not available and not administered on September 8, 9, and 11, 2018. On September 28, 2018 at 11:00 a.m., the Minimum Data Set (MDS - resident assessment tool) /Licensed Vocational Nurse (LVN) 2 was interviewed. MDS/LVN 2 stated the medication was not administered as ordered. MDS/LVN 2 stated the medications should have made available, and administered as ordered. MDS/LVN 2 futher stated OTC medications are usually available in the facility and should have been administered as ordered. 19. On September 28, 2018, Resident 69's record was reviewed. Resident 69 was admitted to the facility on May 12, 2018. The Physician's order included, "Vitamin D3...tablet; 1000 unit;...2 tab...Once a Day...Start...8/06/2018, at 9:00 a.m..." The Medication Administration Record (MAR) for September 2018, indicated Vitamin D3 medication was not available and not administered for on 9/09/2018, at 9:00 a.m. On September 28, 2018 at 11:00 a.m., the Minimum Data Set (MDS - resident assessment tool)/Licensed Vocational Nurse (LVN) 2 was interviewed. MDS/LVN 2 stated the Vitamin D3 medication was not administered as ordered. MDS/LVN 2 stated the medication should have been made available, and administered as ordered. MDS/LVN 2 futher stated OTC (over-thecounter) medications are usually available in the facility and should have been administered as ordered. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 79 of 140 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 10/01/2018 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 20. On September 28, 2018, Resident 53's record was reviewed. Resident 53 was admitted to the facility on July 17, 2018. The Physician's order included: - "Acidophilus...[OTC] (over-thecounter)...capsule...2 CAP...Once a Day...Start 08/05/2018, at 9:00 a.m..."; and - "Pro-stat...[OTC] liquid; 15-100 gram-kcal (kilo calorie/30 ml (milliliter)...30 MLS...Twice a Day...Start 07/23/2018..." The Medication Administration Record (MAR) for August 2018, indicated medications were not available and not administered for to Resident 53 on the following dates: - Acidophilus cap on August 7, 2018, at 9:00 a.m.; and - Pro-stat on August 21, 2018, at 9:00 a.m. On September 28, 2018 at 11:00 a.m., the Minimum Data Set (MDS - resident assessment tool)/Licensed Vocational Nurse (LVN) 2 was interviewed. MDS/LVN 2 stated the medications were not administered as ordered. MDS/LVN 2 stated the medications should have been ordered/re-ordered, made available, and administered as ordered. MDS/LVN 2 further stated OTC medications are usually available in the facility and should have been administered as ordered. 21. On September 28, 2018, Resident 194's record was reviewed. Resident 194 was admitted to the facility on September 18, 2018. The Physician's order included, "pantoprazole tablet; 20 mg...Every 12 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 80 of 140 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 10/01/2018 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 hours...Start...09/09/2018, at 9:00 a.m. and 9:00 p.m..." The Medication Administration Record (MAR) for September 2018, indicated pantoprazole medication was not available and not administered on September 9, 2018, at 9:00 p.m. On September 28, 2018 at 11:00 a.m., the Minimum Data Set (MDS - resident assessment tool)/Licensed Vocational Nurse (LVN) 2 was interviewed. MDS/LVN 2 stated the pantoprazole medications was not administered as ordered. MDS/LVN 2 stated new admission medication should have been ordered, made available, and administered as ordered. MDS/LVN 2 further stated OTC (over-thecounter) medications are usually available in the facility and should have been administered as ordered. 22. On September 28, 2018, during a medication error investigation, Resident 196's record was reviewed. Resident 196 was admitted to the facility on September 22, 2018. The Physician's order included: - "methadone...10 mg...Every 8 Hours...FOR PAIN...Start...09/22/2018..."; - "pantoprazole tablet...40mg...Once a Day...Start...09/22/2018..."; and - "sucralfate tablet...1 gram...Once a Day...Start...09/22/2018..." The Medication Administration Record (MAR) for September 2018, indicated medications were not available and not administered to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 81 of 140 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 10/01/2018 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 Resident 196 on the the following dates: - Methadone 10 mg on September 22, 2018, at 9:00 a.m.; - Pantoprazole 40mg on September 22, 2018, at 9:00 a.m. and September 23, 2018, at 6:00 a.m.; - Sucralfate 1 gram on September 22, 2018, at 6:45 a.m., 11:45 a.m., and 4:45 p.m., September 23, 2018, at 11:45 a.m., and 4:45 p.m., and September 24, 2018, at 6:45 a.m. On September 28, 2018 at 11:00 a.m., the Minimum Data Set (MDS - resident assessment tool)/Licensed Vocational Nurse (LVN) 2 was interviewed. MDS/LVN 2 stated the medications were not administered as ordered. MDS/LVN 2 stated new admission medications should have been ordered, made available, and administered as ordered. MDS/LVN 2 further stated OTC medications are usually available in the facility and should have been administered as ordered. 23. On September 28, 2018, during a medication error investigation, Resident 198's record was reviewed. Resident 198 was admitted to the facility on September 16, 2018. The Physician's order included: - "Advair Diskus...250-50 mcg (microgram)/dose...1 puff...Twice A Day...Start 09/16/2018..."; and - "nicotine [OTC] patch 24 hour (hr); 14 mg (milligram)/24 hr..." The electronic Medication Administration Record (eMAR) for September 2018, indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 82 of 140 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 10/01/2018 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 medications were not available and not administered to Resident 198 on the following dates: - Advair Diskus inhaler on September 17, 2018, at 9:00 a.m.; and - Nicotine patch on September 17, 2018, at 9:00 a.m. On September 28, 2018 at 11:00 a.m., the Minimum Data Set (MDS - resident assessment tool)/Licensed Vocational Nurse (LVN) 2 was interviewed. MDS/LVN 2 stated the medications were not administered as ordered. MDS/LVN 2 stated new medications should have been ordered, made available, and administered as ordered. 24. On September 28, 2018, during a medication error investigation, Resident 195's record was reviewed. Resident 195 was admitted to the facility on September 11, 2018. The Physician's order indicated, "olanzapine tablet...2.5 mg AT Bedtime..." The electronic medication Administration Record (eMAR) for September 2018, indicated pantoprazole medication was not available and not administered on September 11, 2018, at 9:00 p.m. On September 28, 2018 at 11:00 a.m., the Minimum Data Set (MDS - resident assessment tool)/Licensed Vocational Nurse (LVN) 2 was interviewed. MDS/LVN 2 stated the medication was not administered as ordered. MDS/LVN 2 stated new admission medication should have been ordered, made available, and administered as ordered. 25. On September 28, 2018, Resident 36's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 83 of 140 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 10/01/2018 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 record was reviewed. Resident 36 was admitted to the facility on January 1, 2018. The Physician's order indicated, "Vitamin D3... [OTC] (over-the-counter) tablet...1000 unit...2 tablet...Once A Day...Start...05/26/2018..." The electronic Medication Administration Record (eMAR) for Resident 36 for September 2018, indicated Vitamins D3 medication was not available and not administered on September 9, 2018, at 9:00 a.m. On September 28, 2018 at 11:00 a.m., the Minimum Data Set (MDS - resident assessment tool)/Licensed Vocational Nurse (LVN) 2 was interviewed.MDS/LVN 2 stated the Vitamin D3 medication was not administered as ordered. The MDS/LVN 2 stated the Vitamin D3 medication should have been re-ordered, made available, and administered as ordered. MDS/LVN 2 futher stated OTC medications are usually available in the facility and should have been administered as ordered. On September 28, 2018, at 3:35 p.m., the Administrator was interviewed. The identified medication unavailability for Residents 44, 74, 61, 17, 9, 56, 28, 76, 77, 395, 47, 90, 43, 57, 197, 192, 25, 199, 69, 53, 194, 196, 198, 195, and 36, were discussed. The Administrator stated it was the licensed nurses who were at fault for not having the medication available for the residents. The Administrator stated the nurses should have requested five days before the residents' medication ran out so the pharmacy could deliver the medications on time. The Administrator stated the nurses were putting in the refill request on the day when the resident's medicationhad run out and not available for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 84 of 140 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 10/01/2018 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 administration. On September 28, 2018, at 4:00 p.m., the Director of Nursing (DON) was interviewed. The DON stated the facility's pharmaceutical services for acquiring medications (new orders and refills) was impacted by the new system implementation of medication refill order from cycle to on demand. DON further stated a breakdown was identified when there was no follow up evaluation of the effectiveness of inservices and staff education and had resulted to delay in the delivery of residents medications.

F757 SS=D Drug Regimen is Free from Unnecessary Drugs CFR(s): 483.45(d)(1)-(6)

F757 10/28/2018 §483.45(d) Unnecessary Drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used§483.45(d)(1) In excessive dose (including duplicate drug therapy); or §483.45(d)(2) For excessive duration; or §483.45(d)(3) Without adequate monitoring; or §483.45(d)(4) Without adequate indications for its use; or §483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or §483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 85 of 140 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 10/01/2018 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 This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed for one of 22 residents reviewed (Resident 43), to ensure the medication hydrocodone- acetaminophen (Brand name Norco- narcotic pain medication) was administered to the resident with proper assessment on the indication for use. This failure had the potential for Resident 43 to receive unnecessary medications. Findings: On September 26, 2018, Resident 43's record was reviewed. Resident 43 was admitted to the facility on April 16, 2018, with diagnoses that included multiple sclerosis (disease in which the immune system eats away at the protective covering of the nerves) and open wound to right thigh sequela (condition that is the consequence of a previous disease or injury) Resident 43's Nursing Pain Evaluation Assessment dated July 30, 2018, indicated Resident 43 was at risk for pain related to her diagnosis of multiple sclerosis Resident 43's care plan dated August 2, 2018, indicated, "Problem...Resident expressed alteration in Comfort and Daily Activity due to presence of pain...as caused by...wound...contratures...Spasm...Multiple Sclerosis...Approach...Administer pain medication as ordered..." Resident 43's physician's order, dated March 3, 2017, indicated Resdient 43 may be given Norco tablet 5-325 mg (milligrams) 1 tablet by mouth every four hours as needed for breakthrough pain. Resident 43's Norco count sheet indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 86 of 140 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 10/01/2018 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 Norco was signed out by Licensed Vocational Nurse (LVN) 3 on September 14, 15, 16, 18, and 21, 2018, and LVN 2 had signed out the Norco on September 17 and 18, 2018. There was no documented evidence of pain assessment was conducted on Resident 43 prior to the administration of Norco on those dates. On September 29, 2018, at 1:29 p.m., a concurrent record review anmd interview was conducted with LVN 2. LVN 2 verified she had signed out the Norco medication and administered to Resident 43 on: - September 17 at 8:40 p.m.; and - September 21 at 9 p.m. LVN 2 stated before administering a PRN (as needed) pain medication, she should assess the resident's pain level first prior to giving the medication. LVN 2 stated she should conduct an evaluation for the effectiveness of the medication after the medication was given. LVN 2 stated she did not conduct a pain assessement on Resident 43 prior to administering the Norco because she gave it as a substitute for the routine Morphine tablet (narcotic pain medication) which was unavailable at that time. LVN 2 stated she should have conducted a pain assessement on Resident 43 prior to administering the medication. LVN 2 was aware the Norco was ordered to be given as needed for breakthrough pain. On October 1, 2018, at 10:30 a.m., a concurrent record review and interview was conducted with LVN 3. LVN 3 stated he had FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 87 of 140 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 10/01/2018 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 signed out the Norco form Resident 43's narcotic count sheet and administered to the resident on the following dates: - September 14, 2018, at 9 a.m.; - September 15, 2018, at 9 a.m.; - September 16, 2018, at 8:15 a.m.; - September 18, 2018, at 8:45 a.m; and - September 21, 2018, at 9:40 a.m. LVN 3 stated he admistered the Norco medication to Resident 43 on those dates as a substitute for the routine morphine tablet which was unavailable at that time. LVN 3 was aware Resident 43 had a physician's order for Norco to be given as needed only for breakthrough pain. LVN 3 stated Resident 43's pain assessment had to be conducted prior to administering the Norco medication and the indication for use of the Norco had to be documented. LVN 3 stated he did not conduct a pain assessment prior to administering the Norco to Resident 43. LVN 3 stated he should have conducted a pain assessment for Resident 43 prior to giving the medication. LVN 3 stated he did not have an indication for use of the Norco as administered to Resident 43 on those dates. The facility's policy and procedure titled, "Administration of medications," dated July 6, 2018, was reviewed. The policy indicated, "...As required or indicated for a medication, the individual administering the medication will FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 88 of 140 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 10/01/2018 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 record in the in the resident's medical record...Any complaints or symptoms for which the drug was administered...any results achieved and when those results were observed..."

F758 SS=D Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) 10/28/2018 §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 89 of 140 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 10/01/2018 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 §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed, for one of five residents reviewed for unnecessary medications (Resident 50), to ensure the resident was appropriately assessed and evaluated prior to obtaining an order for the medication Xanax (an anti-anxiety medication). This failure had the potential for the resident to receive unncessary psychotropic medication (medications used to treat mood and behavioral disorders). Findings: 1. On October 1, 2018, at 10 a.m., an observation and an interview was conducted on Resident 50 with the Activity Assistant (AA). Resident 50 was in her wheelchair in the dining room. Resident 50 communicated in Spanish and needed an interpreter. Resident 50 was pleasant and did not exhibit signs of anxiety. The AA stated she had not seen any behavior of anxiety such as yelling out on Resident 50. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 90 of 140 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 10/01/2018 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 AA stated Resident 50 cried but her behavior was easily redirected. On October 1, 2018, at 11:50 a.m., Resident 50's record was reviewed with the Minimum Data Set (MDS - an assessment tool) / Licensed Vocational Nurse (LVN) 2. Resident 50 was re-admitted to the facility on April 25, 2017, with diagnoses that included anxiety. Resident 50's electronic Medication Administration Record (eMAR) for August 2018, indicated Resident 50 was monitored for restlessness, crying, and calling for family until exhaustion, from August 20, 2018 to August 23, 2018. The eMAR indicated Resident 50 did not exhibit any of these behavior during the period of observation. Resident 50's progress note dated August 28, 2018, completed by the Social Service Director (SSD), indicated, "...MD (medical doctor) NOTIFIED OF RESIDENT INCREASE IN BEHAVIORS DUE TO D/C (discontinue) OF XANAX MD STATED TO RETART PREVIOUS ORDER OF XANAX..." A physician's order, dated August 27, 2018, indicated, "Xanax...tablet 0.25 mg (milligram)...1 tab (tablet) oral...every 12 hours...for anxiety M/B (manifested by) yelling out continuously..." There was no documented evidence the facility had observed and monitored Resident 50's behavior yelling out continuously prior to obtaiing the order for Xanax on August 28, 2018. In a concurrent intewrview, MDS/LVN 2 stated Resident 50 was on Xanax for anxiety previously but it was disocntinued on July 31, 2018, due to the resident not exhibiting signs of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 91 of 140 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 10/01/2018 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 agitation at that time. MDS/LVN 2 further stated Resident 50's family had reported to them the resident had increased yelling behavior since the Xanax was discontinued. MDS/LVN 2 stated the nurses did not witnessed Resident 50 exhibit those behavior during the observation period from August 20, 2018 to August 23, 2018. MDS/LVN 2 stated, the facility's policy and procedure prior to obtaining an order for the use psychotropic medication, when a resident exhibit a new behavior, the facility should determine the cause of the behavior, assess the resident exibiting the behavior, attempt non-paharmacological intervention, monitor and document the behavior observed on the resdient for 72 hours. MDS/LVN 2 stated there was no documented evidence Resdient 50 had exhibited signs of agitation prior to obtaining an order for the Xanax 0.25 mg by mouth every 12 hours. On October 1, 2018, at 2:41 p.m., the SSD was interviewed. The SSD verified she was the one who had carried out Resident 50's physician's order for Xanax on August 28, 2018. The SSD stated she had based the indication of continuous yelling from her own observation and Resident 50's family member report. The SSD stated there was no assessment conducted to justify Resident 50's use of Xanax for anxiety as manifested by continuous yelling behavior. The SSD stated there was no documented evidence Resident 50 had exhibited a continuous yelling behavior prior to obatining the order for the Xanax. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 92 of 140 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 10/01/2018 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 SSD stated her observation alone and the report of yelling behavior from Resident 50's family member would not "warrant" the use of the medication Xanax. The facility's policy and procedure dated, titled, "Behavioral Symptoms Associated with Dementia Management, " dated July 6, 2018, was reviewed. The policy indicated, "...Describe the Behavior: The Licensed Nurse, and/or Social Services Director/Designee, and other members of the facility's Interdisciplinary Team (IDT) will describe the resident's behavior... Perform Assessement: the Licensed Nurse and/or the Social Services Director/Designee will notify the Attending Physician and/or the mental health Professional of the resident's behavior(s) assessment. Prior to the initiation of any specific non-medication or medication treatment, a thorough assessment of the resident should take place... facility's IDT will evaluate the environment and implement non-pharmacological interventions...If unsuccessful, the Licensed Nurse and/or Social Services Director/Designee will notify the Attending Physician for appropriate management of agitaion/distress syndrome for additional nonpharmacologic, when where appropriate, pharmacologic interventions as last resort..."

F759 SS=E Free of Medication Error Rts 5 Prcnt or More CFR(s): 483.45(f)(1)

F759 10/28/2018 §483.45(f) Medication Errors. The facility must ensure that itsFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 93 of 140 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 10/01/2018 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 §483.45(f)(1) Medication error rates are not 5 percent or greater; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the medication error rate was below five percent (5%) when five medication errors out of 27 opportunities observed for four of seven residents (Residents 61, 74, 20, and 83). These failures resulted to a medication error rate of 18.52% and could result in the residents not receiving the full therapeutic effect of the medications. Findings: 1. On September 24, 2018, at 9:19 a.m., a medication pass observation on Resident 61 was conducted with Licensed Vocational Nurse (LVN) 4. LVN 4 was observed verifying medications with the physician's orders in the electronic Medication Administration Record (eMAR) as she prepared the following medications in the medication cup: - One tablet of vitamin C (supplement); - One capsule of cranberry extract (supplement used to prevent urinary tract infection); - One tablet of Furosemide (a diuretic medication); - Two capsule of milk thistle (supplement used to treat liver problem); - One tablet of Klor-Con (potassium chloride an electrolyte supplement) - One tablet of sodium chloride (an electrolyte FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 94 of 140 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 10/01/2018 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 supplement); and - One capsule of zinc sulfate (supplement). LVN 4 stated Resident 61 refused the 9 a.m. dose of his antihypertensive medication (for high blood pressure - that is 140/90 or higher). On September 24, 2018, at 9:30 a.m., LVN 1 administered these medications to Resident 61 then subsequently signed the eMAR. On September 24, 2018, at 12 p.m., Resident 61's record was reviewed. Resident 61 was readmitted to the facility on May 21, 2018, with diagnoses that included liver cirrhosis (a type of liver disease), urinary tract infection, and benign prostatic hyperplasia (BPH enlargement of the prostate gland). Resident 61's physician's order indicated the following medications were scheduled to be administered at 9 a.m.: - "...vitamin C...tablet; 500 mg (milligram)...1 tab (tablet); oral...Once A day; 09:00 AM..." date ordered May 21, 2018; - "...cranberry...400 mg...1 capsule; oral...Once A Day; 09:00 AM..." date ordered May 21, 2018; - "...sodium chloride...1 gram...1 tab; oral...Twice A Day; 09:00 AM..." date ordered May 21, 2018; - "...furosemide...20 mg...1 tab; oral...scrotal swelling Once A Day; 09:00 AM..." date ordered May 22, 2018; - "...potassium chloride...10 mEq (milliequivalent)...1 tab; oral...supplement Once A Day; 09:00 AM..." date ordered May 22, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 95 of 140 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 10/01/2018 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 2018; - "...Valtrex (antiviral medication)...500 mg; 1 tab; oral...PPx (prophylaxis) for Viral Rash Once A Day; 09:00 AM..." date ordered September 20, 2018; - "...zinc sulfate...220 (50) mg...1 capsule; oral...Once A Day; 09:00 AM..." dated May 22, 2018; - "...lactulose solution (medication for treating liver disease); 20 gram/30 ml (milliliter)...45ml (30g total); oral...Cirrhosis Twice A Day; 09:00 AM..." dated May 23, 2018; - "...carvedilol tablet (medication used to treat high blood pressure); 6.25 mg...oral...for HTN (hypertension - high blood pressure)...Twice A Day; 09:00 AM..." dated May 25, 2018; and - "...tamsulosin (medication for BPH)...0.4 mg...1 tab; oral...Once A Day; 09:00 AM..." dated May 31, 2018. On September 24, 2018, at 4:04 p.m., a concurrent record review and interview was conducted with LVN 4. LVN 4 verified Resident 61's medications: lactulose, tamsulosin, and valtrex were scheduled to be given at 9 a.m. LVN 4 was made aware on the following medications not observed to have prepared and administered to Resident 61: - Lactulose; - Tamsulosin; and - Valtrex. LVN 4 stated the Lactulose was given to Resident 61 at 8:00 a.m., as requested by the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 96 of 140 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 10/01/2018 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 resident. LVN 4 stated the Tamsulosin and Valtrex were not administered to Resident 61 because it was not available. LVN 4 stated when medications were not available, medication refill should have been requested and a follow up call should have been made to the pharmacy for the time of delivery. LVN 4 stated the physician should have been notified of medications not administered to the residents. LVN 4 stated the residents' medication refill should have been requested from the pharmacy five days before the last dose. LVN 4 stated it was important for the refill request submitted ahead of time to ensure the resident's medication would be available for administration. LVN 4 stated the refill of the missing medications were not yet delivered. LVN 4 stated she did not follow up with the pharmacy for the status of the refill requests. LVN 4 stated she did not notify the physician on Resident 61's medications: tamsulosin and valtrex, were not given because it was unavailable. 2. On September 24, 2018, at 9:35 a.m. a medication pass observation on Resident 74 was conducted with LVN 4. LVN 4 was observed verifying medications with the physician's orders in the electronic Medication Administration Record (eMAR) as she prepared the following medications in the medication cup: - One tablet of aspirin (prophylaxis for stroke); FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 97 of 140 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 10/01/2018 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 - One tablet of atenolol (medication used for high blood pressure - that is 140/90 or higher); and - One tablet of diltiazem (medication used for high blood pressure). On September 24, 2018, at 9:50 a.m., LVN 4 administered these medications to Resident 74 then subsequently signed the eMAR. On September 24, 2018, at 12:30 p.m., Resident 74's record was reviewed. Resident 74 was admitted to the facility on February 8, 2017, with diagnoses that included hypertension (high blood pressure). Resident 74's physician's order indicated the following medications were scheduled to be administered at 9 a.m.: - "...aspirin...81 mg (milligram)...1 tablet; oral...Once A day; 09:00 AM..." date ordered June 29, 2017; - "...atenolol...50 mg...1 tablet; oral...Once A Day; 09:00 AM..." date ordered May 31, 2018; - "...Lasix (a diuretic medication)...20 mg...1 tablet; oral...for HTN (hypertension)...Once A Day; 09:00 AM..." date ordered May 31, 2018; and - "...diltiazem...60 mg...oral...Once A day; 09:00 AM..." date ordered July 23, 2018. On September 24, 2018, at 4:10 p.m., a concurrent record review and interview was conducted with LVN 4. LVN 4 verified Resident 74's lasix was administered to the resident at 9 a.m. LVN 4 was made aware the Lasix medication FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 98 of 140 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 10/01/2018 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 was not observed to have prepared and administered to Resident 74. LVN 4 stated she would check the Lasix medication pack to verify the medication was administered on September 24, 2018, at 9 a.m. After checking her medication cart, LVN 4 stated Resident 74 did not have a medication pack for Lasix. LVN 4 stated Resident 74's Lasix was not available to be administered. LVN 4 stated she made a mistake in signing the eMAR for 9 a.m. dose today as administered. LVN 4 stated she did not give Resident 74's Lasix today because it was not available. LVN stated she should have compared the medication she is preparing for the resident to the physician's order in the eMAR before signing as administered medication. 3. On September 24, 2018, at 10:01 a.m. a medication pass observation on Resident 20 was conducted with LVN 3. LVN 3 was observed verifying medications with the physician's orders in the electronic Medication Administration Record (eMAR) as he prepared the following medications in the medication cup: - One capsule of cranberry extract (supplement used to prevent urinary tract infection); and - 30 milliliter (ml) of lactulose (for constipation). On September 24, 2018, at 10:10 a.m., LVN 3 administered these medications to Resident 20 then subsequently signed the eMAR. On September 24, 2018, at 2 p.m., Resident 20's record was reviewed. Resident 20 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 99 of 140 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 10/01/2018 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 admitted to the facility on December 11, 2017, with diagnoses that included dementia (a disease associated with decline of memory that affects one's daily function in life). Resident 20's physician's order indicated the following medications were scheduled to be administered at 9 a.m.: - "...rivastigmine patch (medication used to treat symptoms of dementia) 24 hour; 9.5 mg (milligram)/24 hr (hour)...1 PATCH; transdermal...DEMENTIA Once A day; 09:00 AM..." date ordered December 11, 2017; - "...lactulose solution 20 gram/30 ml...30 ml; oral...Once A Day; 09:00 AM..." date ordered December 12, 2017; and - "...cranberry capsule; 425 mg...1 CAPSULE; oral...Once A Day; 09:00 AM..." date ordered March 20, 2018. On September 24, 2018, at 3:35 p.m., a concurrent record review and interview was conducted with LVN 3. LVN 3 verified Resident 61 had the Rivastigmine patch scheduled to be given at 9 a.m. LVN 3 was made aware the Rivastigmine was not observed to have prepared and administered to Resident 20. LVN 3 stated the Rivastigmine was not administered to Resident 20 because it was not available. LVN 3 stated when medications were not available, medication refill should have been requested and a follow up call should have been made to the pharmacy for delivery. LVN 3 stated the physician should be have been notified of medications not administered to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 100 of 140 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 10/01/2018 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 residents. LVN 3 stated the medication refill should have bene requested from the pharmacy five days before the last dose. LVN 3 stated it was important for the refill request to be submitted ahead of time to ensure the resident's medication would be available for administration. LVN 3 stated he made a refill request two days ago when Resident 20's Rivastigmine patch was down to two doses. LVN 3 stated the refill of the missing medications were not yet delivered. LVN 3 stated he did not follow up with the pharmacy for the status of the refill requests. LVN 3 stated he did not notify the physician on Resident 20's Rivastigmine was not given today because it was not available. 4. On September 24, 2018, at 11 a.m., a medication pass observation on Resident 83 was conducted with LVN 3. LVN 3 was observed holding the Advair Diskus (medication used for treatment of chronic obstructive pulmonary disease [COPD] - an inflammatory lung disease that causes obstructed airflow from the lungs), told Resident 83 he would administer one puff. LVN 3 placed the Advair Diskus mouth piece on Resident 83's mouth, press the Advair Diskus and the resident quickly took a breath. LVN 3 immediately removed the Advair Diskus from the resident's then assisted the resident to swish and spit with the water. In the same medication observation pass, LVN 3 was observed providing instructions to Resident 83 on how she would be taking her two puffs of Spiriva capsule (medication used for treatment of COPD) using the inhaler FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 101 of 140 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 10/01/2018 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 device. LVN 3 was instructing the resident on how to inhale the puff, LVN 3 was instructing the resident to hold her breath after the puff was given while LVN 3 was counting slowly from one to five, and LVN 3 instructed Resident 83 to take two slow deep breaths after each puff. Resident 83 was able to follow when given instructions on her inhaler medications. On September 24, 2018, at 2:15 p.m., Resident 83's record was reviewed. Resident 83 was readmitted to the facility on September 25, 2017, with chronic obstructive pulmonary disease (COPD - an inflammatory lung disease that causes obstructed airflow from the lungs). Resident 83 had cognitive decision-making. On September 25, 2018, at 8:50 a.m., a concurrent record review and interview was conducted with LVN 3. LVN 3 stated Resident 83 was alert, oriented and able to follow instructions. LVN 3 stated he did not read the Advair Diskus manufacturer's guide for instruction on how to administer the medication. LVN 3 stated he only followed the special instruction on the physician's order written in the electronic Medication Administration Record (eMAR). LVN 3 stated the special instruction on the eMAR was to rinse the resident's mouth with water after use of the Advair. LVN 3 verified the Step 3 instructions written on manufacturer's guide for Advair Diskus was, "...Step 3. Inhale your medicine. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 102 of 140 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 10/01/2018 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 - Before you breathe in your dose from the DISKUS, breathe out (exhale) as long as you can while you hold the DISKUS level and away from your mouth...Do not breathe into the mouthpiece. - Put the mouthpiece to your lips...Breathe in quickly and deeply through the DISKUS. Do not breathe in through your nose. - Remove the DISKUS from your mouth and hold your breath for about 10 seconds, or for as long as is comfortable for you... - Breathe out slowly as long as you can..." LVN 3 stated he did not give Resident 83 the instructions from the manufacturer's guide before administering the Advair Diskus to the resident. LVN 3 stated he should have read the manufacturer's guide before using the Advair Diskus so he could give Resident 83 proper instructions to ensure the resident inhaled the medication as ordered by the physician. The facility's policy and procedure titled, "General Dose Preparation and Medication Administration," dated July 6, 2018, indicated, "...Facility staff should comply with facility policy, applicable law and the State Operations Manual when administering medications...verify each time a medication is administered that it is the correct medication...Provide the resident with any necessary instructions (e.g., using an inhaler)...Document necessary medication administration/treatment information..." The facility's policy and procedure titled, "Reordering, Changing, and Discontinuing Orders," dated July 6, 2018, indicated, "...Facilities are encouraged to reorder FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 103 of 140 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 10/01/2018 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 medications electronically...Facility should review the transmitted re-orders for status and potential issues and Pharmacy response..."

F760 SS=H Residents are Free of Significant Med Errors CFR(s): 483.45(f)(2)

F760 10/28/2018 The facility must ensure that its§483.45(f)(2) Residents are free of any significant medication errors. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure 12 of 91 residents reviewed (Residents 44, 61, 74, 17, 9, 56, 28, 76, 90, 43, 57, and 197) were free of significant error when: 1. Resident 44 did not received her Fentanyl patch (narcotic pain medication) from September 10 to 15, 2018. This failure resulted for the resident to experienced increase pain. 2. Resident 44, who had unstable high blood sugar levels, did not received her prescribed Levimir insulin (medication to treat diabetes - a disease that result in too much sugar in the blood) on September 22, 2018. In addition, Resident 44's blood sugar level were not checked on August 25, 2018, at 11:30 a.m. and September 22, 2018, at 6:30 a.m. to determine the resident's need to receive Novolin R insulin (medication to treat diabetes). These failures could jeopardize Resident 44's health and safety for having unstable high blood sugar levels. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 104 of 140 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 10/01/2018 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 3. Residents 44, 61, and 74 received their prescribed antihypertensive medications (for treatment of high blood pressure - that is 140/90 or higher) on multiple occasions in the month of August and September 2018, when the residents' blood pressure reading where below the parameters as indicated on the physician's order. This failure could jeopardize the residents' health and safety when putting the residents at risk for hypotension (low blood pressure - less than 90/60). 4. Resident 17 did not received his Methadone (narcotic pain medication) on multiple occasions. This failure resulted for the resident to experienced increase pain. 5. Resident 9 did not received her Lyrica (medication that treats nerve and muscle pain) on multiple occasions. This failure resulted for the resident to experienced increase neuropathy pain (nerve pain). 6. Resident 56 did not received her Fentanyl patch (narcotic pain medication) and Percocet (narcotic pain medication) on multiple occasions. This failure resulted for the resident to experienced increase pain. 7. Resident 28 did not received her Toradol (pain medication) on multiple occasions. This failure resulted for the resident to experienced increase pain. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 105 of 140 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 10/01/2018 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 8. Resident 76 did not received his Methadone on multiple occasions. This failure resulted for the resident to experienced increase pain. 9. Resident 90 did not received her Gabapentin (for neuropathy) on multiple occasions. This failure put the resident at risk to experience increase neuropathy pain. 10. Resident 43 did not received her Morphine (narcotic pain medication) on multiple occasions. This failure put the resident at risk to experience increase pain. 11. Resident 57 did not received his Bactrim (antibiotic for urinary tract infection [UTI]) as a prophylaxis for UTI on multiple occasions. This failure could jeopardize Resident 57's health and safety for putting the resident at risk of developing UTI. 12. Resident 197 did not received his Travatan eye drop (for treatment of glaucoma - eye disease that can cause vision loss and blindness) and Xalatan eye drop (for treatment of glaucoma). This failure could jeopardize Resident 197's health and safety for not receiving the resident's prescribed medication for his glaucoma. Findings: 1. On September 25, 2018, Resident 44's record was reviewed. Resident 44 was readmitted to the facility on January 8, 2018, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 106 of 140 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 10/01/2018 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 with diagnoses that included myalgia (muscle pain), lumbago (low back pain), and chronic pain syndrome. Resident 44 had cognitive decision-making. Resident 44 physician's order indicated, "...fentanyl...patch 72 hour; 12 mcg/hr (microgram/hour)...apply 1 patch transdermal (application of a medication through the skin)...Every 72 Hours; 09:00 AM..." date ordered February 3, 2018. Resident 44's electronic Medication Administration Record (eMAR) for the month of September 2018, indicated Resident 44's fentanyl patch was scheduled to be changed on September 10, 2018. Further review of Resident 44's eMAR for September 2018, indicated the following: - "...Monitor FENTANYL patch placement Qshift... - 09/10/2018 03:56 PM...waiting on pharmacy to deliver... - 09/12/2018 03:01 PM...PHARMACY WILL FAX (name of doctor) for continuous (sic)... - 09/12/2018 05:18 PM Not Administered: On Hold... - 09/13/2018 02:10 AM Not Administered: On Hold... - 09/13/2018 01:42 PM Not Administered: On Hold... - 09/13/2018 04:20 PM Not Administered: Drug/Item unavailable... - 09/14/2018 01:09 AM Not Administered: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 107 of 140 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 10/01/2018 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 Drug/Item unavailable... - 09/15/2018 11:38 AM Not Administered...off..." Resident 44's Fentanyl patch narcotic count sheet with a delivery date of the medication on August 10, 2018, containing 10 patch indicated the 10th patch was used on September 7, 2018. Resident 44's Fentanyl patch narcotic count sheet with a delivery date of the medication on September 15, 2018, containing 5 patch indicated the first patch was used on September 16, 2018. There was no documented evidence Resident 44's Fentanyl patch was administered on September 10 to 15, 2018. On September 25, 2018, at 11:50 a.m., Resident 44 was interviewed. Resident 44 stated she was always in pain because of her myalgia. Resident 44 stated her Fentanyl patch was important for her to have so she could manage her pain due to myalgia. Resident 44 stated the fentanyl patch would not completely remove her pain but the medication would helped to bring down her pain on a tolerable level. Resident 44 stated she had several days in the month of September 2018 where she did not have the fentanyl patch. Resident 44 stated the nurses told her the fentanyl patch was not available because the pharmacy was waiting for the physician's authorization. Resident 44 stated her pain level on the days she did not have the fentanyl patch were "8 out of 10" (pain rating scale 0 to 10: 8-10 severe FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 108 of 140 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 10/01/2018 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 pain). Resident 44 stated because of severe pain she mostly stayed in bed. Resident 44 further stated, "I sleep it off...so not to feel the pain." On October 1, 2018, at 5:38 p.m., a concurrent record review and interview was conducted with Minimum Data Set (MDS - an assessment tool) / Licensed Vocational Nurse (LVN) 2. MDS/LVN 2 verified fentanyl patch was not given to Resident 44 from September 10 to September 15, 2018, because it was not available. MDS/LVN 2 verified there was no documented evidence Resident 44's pain assessment was conducted on September 10 to 15, 2018. MDS/LVN 2 verified there was no documented evidence MD was notified of the fentanyl patch not administered to Resident 44 when it was not available. On September 28, 2018, at 1:05 p.m., LVN 5 was interviewed. LVN 5 stated she was the nurse assigned to Resident 44 on September 13, 2018. LVN 5 stated Resident 44 was scheduled for a fentanyl patch on that day, but the medication was not available. LVN 5 stated Resident 44 needed her fentanyl patch for pain management. LVN 5 stated the fentanyl patch was not available because the pharmacy was waiting for the physician's authorization. LVN 5 stated she did not followed up with the pharmacy for the status of Resident 44's fentanyl patch refill. LVN 5 stated she should have coordinated with the pharmacy in obtaining the physician's authorization for fentanyl patch order. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 109 of 140 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 10/01/2018 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 LVN 5 stated she did not notified the physician when Resident 44's fentanyl patch was not available. LVN 5 stated she should have notified the physician and asked for alternative pain medication Resident 44 when fentanyl patch was not available for Resident 44. LVN 5 stated she did not have documented evidence of Resident 44's pain assessment on September 13, 2018, when she was the assigned nurse. On September 25, 2018, at 3:15 p.m., the Director of Nursing (DON) was interviewed. The DON stated she was not aware the fentanyl patch for Resident 44 was not available because the pharmacy was waiting for the physician's authorization. The DON stated the nurses should have notified the physician when fentanyl was not available. The DON stated the nurses should have asked the physician for alternative pain medication while fentanyl patch was not available for Resident 44. The DON stated it is not acceptable for Resident 44 not to have the fentanyl patch nor an alternative pain medication for several days. On October 1, 2018, Resident 44's care plan for pain with a reviewed and revised date of September 24, 2018 was reviewed. The care plan for pain indicated, "...Goal...Resident will be pain free or relieved from pain...Approach...Administer pain medication as ordered...Assess level of pain...Consult MD if above measures fail to provide adequate pain relief..." 2. On September 25, 2018, Resident 44's record was reviewed. Resident 44 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 110 of 140 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 10/01/2018 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 readmitted to the facility on January 8, 2018, with diagnoses that included diabetes. Resident 44 had cognitive decision-making. Resident 44 physician's order indicated, - "...Levemir...100 unit/mL (milliliter)...80 units...Once A Day; 06:30 AM..." date ordered July 25, 2018; and - "...Novolin R...per sliding scale (progressive increase on the insulin dose, based on predefined blood glucose ranges...Before Meals; 06:30 AM, 11:30 AM, 04:30 PM..." date ordered January 8, 2018. Resident 44's electronic Medication Administration Record (eMAR) for the month of August 2018, indicated the following: - Resident 44's blood sugar was not documented on August 25, 2018, at 11:30 a.m.; - From August 1 to 31, 2018, Resident 44's blood sugar level ranges from 230 mg/dl (milligram/deciliter) to 400 mg/dl (above 126 mg/dl was diabetic); and - Resident 44 was receiving Novolin R every day from August 1 to 31, 2018, at 6:30 a.m., 11:30 a.m., and 4:30 p.m., except on August 25, 2018, at 11:30 a.m. Resident 44's eMAR for the month of September 2018, indicated the following: - Resident 44's blood sugar was not documented on September 22, 2018, at 6:30 a.m. - Resident 44's Levemir insulin was not administered on September 22, 2018, at 6:30 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 111 of 140 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 10/01/2018 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 a.m. - From September 1 to 25, 2018, Resident 44's blood sugar level ranges from 262 mg/dl to 461 mg/dl; and - Resident 44 was receiving Novolin R every day from September 1 to 25, 2018, at 6:30 a.m., 11:30 a.m., and 4:30 p.m., except on September 22, 2018, at 6:30 a.m. On October 1, 2018, at 2:37 p.m., a concurrent record review and interview was conducted with Minimum Data Set (MDS - an assessment tool) / Licensed Vocational Nurse (LVN) 2. MDS/LVN 2 verified: - Resident 44's eMAR for the month of August 2018, had no documented evidence Resident 44's blood sugar level was documented on August 25, 2018, at 11:30 a.m.; and - Resident 44's eMAR for the month of September 2018, had no documented evidence Resident 44's blood sugar level was documented on September 22, 2018 and the Levemir insulin was not administered to the resident on September 22, 2018. MDS/LVN 2 stated if there was no documentation on the eMAR it means the blood sugar was not checked and the insulin was not given. MDS/LVN 2 stated it was important for Resident 44's blood sugar to be checked before each meal, and insulin to be administered as indicated on the physician's order. MDS/LVN 2 further stated monitoring of blood sugar level and administering the prescribed insulin to Resident 44 should be done to help FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 112 of 140 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 10/01/2018 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 manage the resident's diabetes and to prevent adverse consequences of having a high blood sugar level. On October 1, 2018, Resident 44's care plan for diabetes with a reviewed and revised date of September 27, 2018 was reviewed. The care plan for diabetes indicated, "...Goal...Resident's blood sugar level will remain stable...Resident's sign and symptoms of hypo/hyperglycemia will improve with interventions...Approach...Blood sugar checked as ordered...Follow sliding scale if applicable...Insulin as ordered..." The facility's policy and procedure titled, "Medication Administration Times," dated July 6, 2018, indicated, "...Facility should ensure that authorized personnel...administer medications according to times of administration as determined by...physician..." 3a. On September 25, 2018, Resident 44's record was reviewed. Resident 44 was readmitted to the facility on January 8, 2018, with diagnoses that included hypertension (high blood pressure) and congestive heart failure (CHF - a condition that affects the pumping power of the heart muscles). Resident 44 had cognitive decision-making. Resident 44 physician's order indicated, - "...Lisinopril (antihypertensive medication) tablet; 5 mg (milligram)...1 tablet; oral...hold for sbp (systolic blood pressure - the first number on the blood pressure (BP) reading) less than 100...Once A Day; 09:00 AM..." date ordered January 8, 2018; - "...metoprolol (antihypertensive medication) tablet; 100 mg...1 tablet; oral ...hold for sbp less than 100...Twice A Day; 09:00 AM, 05:00 PM ..." date ordered January 8, 2018; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 113 of 140 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 10/01/2018 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 - " ...spironolactone (medication for CHF) tablet; 25 mg...0.5 tablet; oral...hold for sbp less than 100...Once A Day; 09:00 AM..." date ordered January 8, 2018; Resident 44's physician's order had no documented evidence the resident's antihypertensive medications where change nor discontinued after January 8, 2018. Resident 44's electronic Medication Administration Record (eMAR) for the month of August 2018, indicated the following: - Resident 44's BP was 98/68 on September 15, 2018 at 5 p.m., the resident was given Metoprolol 100 mg (1 tablet); - Resident 44's BP was 98/62 on September 21, 2018 at 5 p.m., the resident was given Metoprolol 100 mg (1 tablet); and - Resident 44's BP was 92/68 on September 28, 2018 at 9 a.m., the resident was given Lisinopril 5 mg (1 tablet), Metoprolol 100 mg (1 tablet), and Spironolactone 25 mg (1/2 tablet). Resident 44's electronic Medication Administration Record (eMAR) for September 1 to 25, 2018, indicated the following: - Resident 44's BP was 98/62 on September 5, 2018 at 5 p.m., the resident was given Metoprolol 100 mg (1 tablet); - Resident 44's BP was 93/60 on September 7, 2018 at 9 a.m., the resident was given Lisinopril 5 mg (1 tablet); - Resident 44's BP was 98/56 on September 12, 2018 at 5 p.m., the resident was given Metoprolol 100 mg (1 tablet); FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 114 of 140 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 10/01/2018 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 - Resident 44's BP was 98/72 on September 17, 2018 at 5 p.m., the resident was given Metoprolol 100 mg (1 tablet); and - Resident 44's BP was 98/66 on September 22, 2018 at 9:00 a.m., the resident was given Lisinopril 5 mg (1 tablet), Metoprolol 100 mg (1 tablet), and Spironolactone 25 mg (1/2 tablet). On October 1, 2018, at 9:31 a.m., a concurrent record review and interview was conducted with Registered Nurse (RN) 2. RN 2 verified Resident 44 had the following medications: Lisinopril, Metoprolol, and Spironolactone. RN 2 stated Resident 44's antihypertensive medications were not change nor discontinued since the order date of January 8, 2018. RN 2 verified Resident 44's antihypertensive medications were administered on multiple occasions to the resident when Resident 44's BP was below the indicated sbp parameter. RN 2 stated Resident 44 should have not given the antihypertensive medications when her sbp was below indicated parameter. RN 2 stated the resident would be at risk for hypotension. 3b. On September 25, 2018, Resident 61's record was reviewed. Resident 61 was readmitted to the facility on May 21, 2018. Resident 61 was self-responsible. Resident 61 physician's order indicated, "...carvedilol (antihypertensive medication) tablet; 6.25 mg (milligram); oral...for HTN (hypertension - high blood pressure). Hold for sbp (systolic blood pressure - the first number on the blood pressure (BP) reading) < (less than) 120...Twice A Day; 09:00 AM, 05:00 PM..." date ordered May 25, 2018. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 115 of 140 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 10/01/2018 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 Resident 61's physician's order had no documented evidence the resident's antihypertensive medications where change nor discontinued after May 25, 2018. Resident 61's electronic Medication Administration Record (eMAR) for the month of August 2018, indicated the following: - Resident 61's BP was 110/70 on August 14, 2018 at 9 a.m., the resident was given Carvedilol 6.25 mg; - Resident 61's BP was 108/70 on August 16, 2018 at 9 a.m., the resident was given Carvedilol 6.25 mg; - Resident 61's BP was 110/70 on August 21, 2018 at 9 a.m., the resident was given Carvedilol 6.25 mg; - Resident 61's BP was 107/72 on August 23, 2018 at 5 p.m., the resident was given Carvedilol 6.25 mg; and - Resident 61's BP was 116/69 on August 30, 2018 at 9 a.m., the resident was given Carvedilol 6.25 mg; Resident 61's electronic Medication Administration Record (eMAR) for September 1 to 25, 2018, indicated the following: - Resident 61's BP was 110/70 on September 4, 2018 at 9 a.m., the resident was given Carvedilol 6.25 mg; - Resident 61's BP was 112/68 on September 8, 2018 at 9 a.m., the resident was given Carvedilol 6.25 mg; - Resident 61's BP was 117/62 on September FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 116 of 140 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 10/01/2018 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 9, 2018 at 9 a.m., the resident was given Carvedilol 6.25 mg; - Resident 61's BP was 109/58 on September 12, 2018 at 9 a.m., the resident was given Carvedilol 6.25 mg; and - Resident 61's BP was 117/57 on September 14, 2018 at 5 p.m., the resident was given Carvedilol 6.25 mg; On September 28, 2018, at 9:55 a.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN) 4. LVN 4 stated when the resident have antihypertensive medication, the blood pressure (BP) should be checked first. LVN 4 stated if the blood pressure reading was below the indicated parameters, the antihypertensive medication should not be given. LVN 4 stated when antihypertensive medication was given to the resident with the blood pressure below indicated parameter, there could be a risk for the resident to have hypotension. LVN 4 verified Resident 61 received Carvedilol on multiple occasions on the month of August and September 2018, when the resident's BP was below indicated parameter. LVN 4 verified she was the nurse, as documented in the eMAR, who administered the Carvedilol to Resident 61 below indicated parameter on the following dates: - August 14, 16, 21, and 30, 2018; and - September 4, 8, and 12, 2018. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 117 of 140 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 10/01/2018 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 LVN 4 stated she should have not administered the Carvedilol to Resident 61 when the resident's BP was below indicated parameter. 3c. On September 25, 2018, Resident 74's record was reviewed. Resident 74 was admitted to the facility on February 8, 2018, with diagnoses that included hypertension (high blood pressure). Resident 74 was selfresponsible. Resident 74 physician's order indicated, - "...atenolol (antihypertensive medication) tablet; 50 mg (milligram)...1 tablet; oral...hold for SBP (systolic blood pressure - the first number on the blood pressure (BP) reading) less than 100...Once A Day; 09:00 AM..." date ordered May 31, 2018; - "...Lasix (antihypertensive medication) tablet; 20 mg...1 tablet; oral...hold for systolic B/P (blood pressure) < 100 Once A Day; 09:00 AM..." date ordered May 31, 2018; and - " ...diltiazem (antihypertensive medication) tablet; 60 mg; oral...hold for SBP less (sic)110 Once A Day; 09:00 AM..." date ordered July 23, 2018. Resident 74 physician's order had no documented evidence the resident's antihypertensive medications where change nor discontinued after the ordered date. Resident 74's electronic Medication Administration Record (eMAR) for the month of August 2018, indicated the following: - Resident 74's BP was 108/60 on August 7, 2018 at 9 a.m., the resident was given Diltiazem 60 mg; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 118 of 140 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 10/01/2018 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 - Resident 74's BP was 104/60 on August 10, 2018 at 9 a.m., the resident was given Diltiazem 60 mg; and - Resident 74's BP was 99/77 on August 16, 2018 at 9 a.m., the resident was given Atenolol 50 mg, Diltiazem 60 mg, and Lasix 20mg. On September 28, 2018, at 10 a.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN) 4. LVN 4 stated when the resident have antihypertensive medication, the blood pressure (BP) should be checked first. LVN 4 stated if the blood pressure reading was below the indicated parameters, the antihypertensive medication should not be given. LVN 4 stated when antihypertensive medication was given to the resident with the blood pressure below indicated parameter, there could be a risk for the resident to have hypotension. LVN 4 verified Resident 74 received antihypertensive medications on multiple occasions on the month of August 2018, when the resident's BP was below indicated parameter. LVN 4 verified she was the nurse, as documented in the eMAR, who administered the Atenolol, Diltiazem, and Lasix to Resident 61 below indicated parameter on August 16, 2018. LVN 4 stated she should have not administered Resident 61's antihypertensive medications when the resident's BP was below indicated parameter. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 119 of 140 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 10/01/2018 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 facility's policy and procedure titled, "Administering Medications," dated July 6, 2018, indicated, "...Medications shall be administered in a safe and timely manner, and as prescribed...The following information must be checked/verified for each resident prior to administering medications...Vital signs, if necessary..." 4. On September 27, 2018, Resident 17's record was reviewed. Resident 17 was admitted to the facility on December 16, 2016, with diagnoses that included unspecified pain. Resident 17's electronic Medication Administration Record (eMAR) for the month of September 2018, was reviewed . The physician's orders in the eMAR indicated Methadone tablet 5 mg (milligrams) to administer 0.5 mg tablet by mouth every 12 hours for pain management with the goal of "pain level of 0-2/10 (0-2 in a scale of 0-10 being 10 the worst pain)." Further review of Resident 17's eMAR indicated, the resident did not receive his Methadone dose on the following dates: - September 15, 16, and 18, 2018 at 9 a.m. and 9 p.m. - September 19, 2018 the dose at 9 a.m. On September 27, 2018 at 10 a.m., an interview was conducted with Licensed Vocational Nurse (LVN) 2. LVN 2 stated when medications are not available, the licensed nurse should call the pharmacy and asks when the facility is going to receive the medication. LVN 2 further stated she follows up with pharmacy usually after rounds and calls the pharmacy again at the end of the shift. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 120 of 140 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 10/01/2018 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 On September 28, 2018, at 11:20 a.m., a concurrent interview and record review was conducted with LVN 3. LVN 3 verified the Methadone doses were not administered to Resident 17 on September 15, 16, 18, and 19, 2018. LVN 3 stated there was no assessment for pain conducted on September 15, 16, 18, and 19, 2018 for Resident 17. On October 1, 2018 at 10:35 a.m., an interview was conducted with Resident 17. Resident 17 stated he was aware and was notified Methadone was not available by the licensed nurses. Resident 17 stated when he did not received his Methadone, his pain scale was 8 out of 10. Resident 17 further stated it was generalized pain and "It was very bad pain for several days." 5. On September 28, 2018, at 11:03 a.m., Resident 9's record was reviewed with Minimum Data Set (MDS - an assessment tool) / Licensed Vocational Nurse (LVN) 2. Resident 9 was admitted to the facility on August 29, 2017, with diagnoses that included peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to the limbs), and radiculopathy (a pinched nerve causing pain). Resident 9's history and physical indicated she had the capacity to understand and make health care decisions. Resident 9's electronic medication administration record (eMAR) for the month of September 2018, indicated: - "...Lyrica (pregabalin) capsule; 75 mg...1 capsule; oral...Twice A Day...neuropathy... FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 121 of 140 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 10/01/2018 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 Reasons/Comments: Not Administered: Drug/Item Unavailable: 09/13/2018, 9:00 AM...09/13/2018, 5:00 PM...09/14/2018, 9:00 AM..." In a concurrent interview MDS/LVN 2 acknowledged lyrica was not administered to Resident 9 on multiple occasions because the drug was unavailable. MDS/LVN 2 stated there was no documented evidence Resident 9's pain assessments were conducted when the lyrica was not administered to the resident on those dates. MDS/LVN 2 stated there was no documented evidence the physician was informed of the missed doses of lyrica for Resident 9. On October 1, 2018, at 10:52 a.m., Resident 9 was observed sitting on her wheelchair inside her room. In a concurrent interview, Resident 9 stated she was made aware by the nurse on multiple occasions that lyrica was unavailable, but could not recall the exact dates when it was. Resident 9 stated she felt "terrible" when she missed her lyrica medication. Resident 9 further stated she felt as if there was a "tight band-aid" around her fingers, and her fingers were numb, and felt like "more than a tingling sensation." 6. On September 28, 2018, at 10:58 a.m., Resident 56's record was reviewed with Minimum Data Set (MDS - an assessment tool) / Licensed Vocational Nurse (LVN) 2. Resident 56 was admitted to the facility on June 17, 2018, with diagnoses that included non-healing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 122 of 140 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 10/01/2018 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 wounds of both lower extremities, pain in right shoulder, and dorsalgia (low-back pain). Resident 56's history and physical indicated she had the capacity to understand and make health care decisions. Resdient 56's electronic medication administration record (eMAR) for the month of August 2018, indicated: - "...fentanyl...patch 72 hour; 12 mcg/hr (microgram per hour- a unit of measurement)...1 patch; transdermal...Every 72 Hours...for pain control... Reasons/Comments: Not Administered: Drug/Item Unavailable: August 4, 2018, 9:00 AM...and 8/16/2018, 9:00 AM..." In a concurrent interview, MDS/LVN 2 acknowledged fentanyl patch was not administered on multiple occasions because the drug was unavailable. MDS/LVN 2 stated there was no documented evidence Resident 56's pain assessments were conducted when fentanyl patch were not administered on those dates. LVN/MDSN stated there was no documented evidence the physician was informed of the missed doses of fentanly patch for Resident 56. On October 1, 2018, at 10:41 a.m., Resident 56 was observed awake and alert, while sitting at the side of her bed, rubbing her legs with her hands. In a concurrent interview, Resident 56 stated she currently had severe pain on both lower legs and she just took her pain medication. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 123 of 140 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 10/01/2018 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 Resident 56 stated the nurse had informed her on multiple occasions when her fentanyl patch was unavailable. Resident 56 further stated she felt "terrible pain' when fentanyl patch was not given to her. 7. On September 28, 2018, at 10:41 a.m., Resident 28's record was reviewed with Minimum Data Set (MDS - an assessment tool) / Licensed Vocational Nurse (LVN) 2. Resident 28 was admitted to the facility on June 29, 2018, with diagnoses that included unspecified pain, and malignant neoplasm of the colon (cancer of the large intestine). Resident 28's history and physical indicated he had the capacity to understand and make medical decisions. Resident 28's electronic medicaion administration record (eMAR) for the month of August 2018, indicated: - "...tramadol...tablet; 50 mg...50 MG; oral...Every 4 Hours...PAIN MANAGEMENT... Reasons/Comments: Not Administered: Drug/Item unavailable: 08/04/2018, 6:00 AM...08/04/2018, 10:00 AM...and 08/04/2018, 2:00 PM..." Resident 28's eMAR for the month of September 2018, indicated: - "...tramadol...tablet; 50 mg...50 MG; oral...Every 4 Hours...PAIN MANAGEMENT... Reasons/Comments: Not Administered: Drug/Item unavailable: 09/04/2018, 10:00 AM..." In a concurrent interview, MDS/LVN 2 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 124 of 140 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 10/01/2018 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 acknowledged tramadol was not administered on multiple occasions because the drug was unavailable. MDS/LVN 2 stated there was no documented evidence Resident 28's pain assessment was conducted when tramadol medications were not administered to the resident on those dates. LVN/MDSN stated there was no documented evidence the physician was informed of the missed doses of tramadol for Resident 28. On October 1, 2018, at 10:39 a.m., Resident 28 was observed awake and alert, and lying in bed. In a concurrent interview, Resident 28 stated he was made aware by the nurse on multiple occasions that tramadol was unavailable, but could not recall the exact dates when it was. Resident 28 further stated when he missed his tramadol medication, he felt "terrible pain" from his legs all the way up to his body. 8. On September 28, 2018, at 10:33 a.m., Resident 76's record was reviewed with Minimum Data Set (MDS - an assessment tool) / Licensed Vocational Nurse (LVN) 2. Resident 76 was admitted to the facility on August 8, 2018, with diagnoses that included pain in unspecified lower leg, low back pain, fracture of the right tibial tuberosity (a bone on the right knee), and psychoactive (a medication that changes brain function) substance dependence of methadone. Resident 76's history and physical indicated the resident had the capacity to make health care decisions. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 125 of 140 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 10/01/2018 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 Resident 76's electronic medication administration record (eMAR) for the month of August 2018, indicated: - "...methadone...10 mg (milligram - a unit of measurement)...1 tablet; oral...Twice A Day...chronic pain management... Reasons/Comments: Not Administered: Drug/Item unavailable: 08/09/2018, 9:00 AM...08/15/2018, 5:00 PM...08/17/2018, 9:00 AM... 8/17/2018, 5:00 PM..." Resident 76's eMAR for the month of September 2018, indicated: - "...methadone tablet; 10 mg...0.5 tablet; oral...At Bedtime...for pain management... Reasons/Comments: Not Administered: Drug/Item unavailable: 09/07/2018, 9:00 PM...09/08/2018, 9:00 PM...09/09/2018, 9:00 PM...and 09/10/2018, 9:00 PM..." In a concurrent interview MDS/LVN 2 acknowledged methadone was not administered to Resident 76 on multiple occasions because the drug was unavailable. MDS/LVN 2 stated there was no documented evidence Resident 76's pain assessments were conducted when the methadone was not administered to the resident on those dates. MDS/LVN 2 stated there was no documented evidence the physician was informed of the missed doses of methadone for Resident 76. On October 1, 2018, at 10:46 a.m., Resident 76 was observed awake, alert, and lying in bed. In a concurrent interview, Resident 76 stated, he was told by the nurses when his methadone FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 126 of 140 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 10/01/2018 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 was unavailable but he could not recall the exact dates when it was. Resident 76 stated he needed the methadone to control his chronic pain. Resident 76 further stated he felt "terrible pain" whenever methadone was not administered to him. 9. On September 17, 2018, Resident 90's record was reviewed. Resident 90 was admitted to the facility on November 1, 2016, with diagnoses that included unspecified pain and history of fracture (break in the bone) on the right femur (thighbone). The care plan dated November 30, 2017, indicated, "Problem...Resident expressed alteration in Comfort and Daily Activity due to presence of pain...Approach...Administer pain medication as ordered...Gabapentin (nerve pain medication) 400 mg (milligrams) PO (by mouth) Q (every) 8 hours..." The August 2018 electronic Medication Administration Record (eMAR) indicated Resident 90 had a physician's order, with a start date of June 1, 2018, for gabapentin capsule 400 one capsule to be given by mouth every eight hours for neuropathy. Further review of the August 2018 eMAR indicated, the gabapentin 400 mg was not administered to Resident 90 due to medication unavailability on the following dates: - August 1, 2018, at 6 a.m.; - August 2, 2018, at 6 a.m.; - August 3, 2018, at 6 a.m.; - August 5, 2018, at 6 a.m.; - August 6, 2018, at 6 a.m.; and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 127 of 140 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 10/01/2018 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 - August 9, 2018 at 6 a.m. There was no documented evidence the licensed nurse had notified the physician on Resident 90's missed doses of gabapentin on those dates. In addition, there was no documented evidence the licensed nurse had monitored the resident on the possible side effects of the missed doses. On October 1, 2018, at 8:47 a.m., Resident 90's record was reviewed with Licensed Vocational Nurse (LVN) 6. LVN 6 verified her electronic signatures for the missed doses of gabapentin. LVN 6 stated she was not able to administer the gabapentin because the medication was not available on August 1, 2, 3, 5, 6, and 9, 2018. LVN 6 further stated she did not notify Resident 90's physician on the missed doses of gabapentin on those dates. LVN 6 stated she did not assess the resident for pain when the medication was not given. LVN 6 further stated Resident 90 would be in pain if she missed a dose of her gabapentin. LVN 6 stated she did not notify the pharmacy on the medication unavailability. LVN 6 stated she should have notified Resident 90's physician on the missed doses of Gabapentin and assessed the resident for pain due to the missed doses of Gabapentin. 10. On September 26, 2018, Resident 43's record was reviewed. Resident 46 was admitted to the facility on April 16, 2018, with diagnoses that included multiple sclerosis (disease in which the immune system eats away at the protective covering of the nerves) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 128 of 140 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 10/01/2018 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 and open wound to right thigh sequela (condition that is the consequence of a previous disease or injury) The physician's order dated September 3, 2017, indicated, "morphine...tablet extended release...15 mg (milligrams)...1 tablet oral...every 12 hours...for pain management..." The Nursing Pain Evaluation Assessment dated July 30, 2018, indicated Resident 43 was at risk for pain related to her diagnosis of multiple sclerosis The care plan dated August 2, 2018, indicated, "Problem...Resident expressed alteration in Comfort and Daily Activity due to presence of pain...as caused by...wound...contractures...Spasm...Multiple Sclerosis...Approach...Administer pain medication as ordered...Morphine 15 mg PO q (every) 12h (hours)..." The August 2018 electronic Medication Administration Record (eMAR) indicated the licensed nurse was not able to administer the Morphine 15 mg tablet for pain due to medication unavailability on the following dates: - August 6, 2018, at 9 p.m.; - August 7, 2018, at 9 a.m. and 9 p.m.; - August 8, 2018, at 9 a.m. and 9 p.m.; - August 8, 2018, at 9 p.m.; and - August 23, 2018 at 9 p.m. The September 2018 eMAR indicated the licensed nurse was not able to administer the Morphine 15 mg tablet for pain due to medication unavailability on the following dates: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 129 of 140 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 10/01/2018 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 - September 8, 2018, at 9 a.m.; - September 14, 2018, at 9 a.m. and 9 p.m.; - September 15, 2018, at 9 a.m.; - September 16, 2018, at 9 a.m. and 9 p.m.; - September 17, 2018, at 9 a.m.; - September 18, 2018, at 9 a.m.; - September 19, 2018, at 9 a.m.; - September20, 2018, at 9 a.m. and 9 p.m.; and - September 21, 2018, at 9 a.m. and 9 p.m. There was no documented evidence Resident 43 was assessed and monitored for pain when the medication Morphine was not administered due to medication unavailability in August 2018 and September 2018. On October 1, 2018, at 10:36 a.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN) 3. LVN 3 stated he was not able to administer the 9 a.m. dose of the Morphine tablet to Resident 43 on September 8, 14, 15, 16, 17, 18, and 21, 2018, because it was unavailable. LVN 3 stated Resident 43 would be experiencing pain if the medication Morphine was not administered. LVN 3 further stated he did not assess Resident 43's pain when the Morphine was not given on those dates. LVN 3 stated he did not have documented evidence the physician was notified when the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 130 of 140 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 10/01/2018 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 morphine was not administered to Resident 43 on those dates. LVN 3 stated he should have assessed and monitored Resident 43 for the possible side effects from missing the dose of morphine on multiple occasions. 11. On September 28, 2018, Resident 57's record was reviewed. Resident 57 was admitted to the facility on April 14, 2018, with diagnoses that included benign prostatic hyperplasia (BPH - enlarged prostate gland that can cause uncomfortable urinary symptoms, such as blocking the flow of urine out of the bladder...cause bladder, urinary tract or kidney problems with lower urinary tract infection [UTI]). The physician's order dated August 9, 2018, indicated, "Bactrim...400-800 mg (milligram)...1 tablet Once A Day Every Other Day for prophylaxis (action taken to prevent disease)..." The Medication Administration Record (MAR) for September 2018, indicated Bactrim 400-800 mg was documented not available and not administered on September 2, 4, 10, and 12, 2018. On September 28, 2018, at 9:33 a.m., Registered Nurse (RN) 1 was interviewed. RN 1 verified Bactrim was not administered to Resident 57 on September 2, 4, 10, and 12, 2018, because it was not available. RN 1 stated the Bactrim was in the OMNIcell (ADDS - automatic drug dispenser system). RN 1 further stated Bactrim should have taken out from the OMNIcell and should have been administered to Resident 57 on September 2, 4, 10, and 12, 2018. In addition, RN 1 stated the physician should FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 131 of 140 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 10/01/2018 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 have been called and informed the Bactrim was not administered as ordered on September 2, 4, 10, and 12, 2018. RN 1 stated Resident 57 had recurrent history of UTI's. RN 1 further stated it is a physician's order that had to be followed to prevent worsening of UTI into sepsis (generalized spread of infection in the body). 12. On September 28, 2018, Resident 197's record was reviewed. Resident 197 was admitted to the facility on September 21, 2018, with diagnoses that included glaucoma. The physician's order dated September 21, 2018, indicated: - "Travatan Z...drops; 0.04 % (percent); amt (amount): 1 drop per eye...At Bedtime..."; and - "Xalatan...drops; 0.005 %; amt: 1 drop per eye...At Bedtime..." Resident 197's electronic Medication Administration Record (eMAR) for September 2018, indicated Travatan and Xalatan were not available and were not administered on September 22, 2018. On September 28, 2018, at 10:22 a.m., the Registered Nurse (RN) and Minimum Data Set (MDS - an assessment tool) / Licensed Vocational Nurse (LVN) was interviewed. RN 1 stated medications for newly admitted residents were usually available on the same day or the next day for the first dose administration. RN 1 stated the physician should have been informed the eyedrop medications fro Resident 197 were not available and not administered as ordered on September 22, 2018. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 132 of 140 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 10/01/2018 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 MDS/LVN 2 stated, Resident 197 was up and about and need his eye medication to maintain adequate vision and function especially when performing activities of daily living (ADL). On October 1, 2018, at 10:00 a.m., Resident 197 was interviewed. Resident 197 stated his right eye had no vision and the left eye gets blurry if he missed his eye medications. Resident 197 further stated, it affects how he see things and and how he functions.

F812 SS=F Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 10/28/2018 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 133 of 140 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 10/01/2018 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 review, the facility failed to ensure sanitary conditions were maintained in the dietary department when: 1. A scoop was stored inside the plastic bin for the pancake mix; 2. A pan of uncooked beef patties was stored on top of cooked puree foods; and 3. The dietary staff failed to perform hand hygiene in between performing tasks while preparing the food items for the lunch tray line. These failures had the potential for the increased risk of cross contamination and create a potential for pathogens to cause foodborne illness among the residents. Findings: 1. On September 24, 2018, at 9: 12 a.m., an inspection of the dry storage area in the kitchen was conducted with the Dietary Supervisor (DS). A plastic bin labeled as pancake mix had a scoop stored inside. The scoop was in direct contact with the pancake mix powder. In a concurrent interview, the DS stated he did not know how long the scoop had been stored inside the bin together with the pancake mix. The DS stated the scoop for the pancake mix should not have been stored inside the bin together with the pancake mix to prevent crosscontamination. The DS further stated the scoop should have been washed after use and stored separately from the pancake mix. 2. On September 24, 2018, at 9: 20 a.m., an inpection of the walk- in refrigerator was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 134 of 140 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 10/01/2018 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 conducted with the DS. A tray cart containing cold food was observed near the refrigerator door opening. An aluminum pan containing raw beef patties was stored on the bottom part shelf of the tray cart. Underneath the pan of raw beef patties were three aluminum containers labeled as tofu puree (liquidized or crushed food), gluten free pasta puree, and gluten free bread. In a concurrent interview, the three aluminum containers were cooked puree food for the residents. The DS further stated the dietary staff should not have stored the pan raw beef patties on top of the cooked puree food. The DS further stated the dietary staff should have removed the cooked puree food from the bottom and stored it on top to prevent cross contamination from the raw beef patties. The facility's policy and procedure titled, "SANITATION AND INFECTION CONTROL ...CANNED AND DRY GOODS STORAGE," dated July 6, 2018, was reviewed. The policy indicated, "Bins holding dry good such as flour, sugar, beans, etc, must be clearly labeled on the lid and front of the container and dated when the product was put into bin. Scoops are to be stored in a separate area, not inside the food containers, and need to be cleaned each time they are used... Cooked foods will be stored on shelves above raw food to prevent contamination from drippings..." 3. On September 26, 2018, at 11:05 a.m., an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 135 of 140 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 10/01/2018 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 observation of the lunch tray line was conducted with Dietary Cook (DC) 1 and DC 2. DC 2 was observed preparing the cooked food item for lunch tray line. DC 2 took several pan containing cooked food covered with foil from the oven and placed it on top of the steam table for temping observation (process of checking the temperature of cooked food). DC 2 removed each covered foil from pan containing the cooked food items and discard each of the foil in the plastic trash bin near the cooking area. DC 2 was observed to be in direct contact with the trash lid each time he discarded an item in the trash can. DC 2 did not wear gloves during the observation and did not perform hand hygiene after each direct contact with the trash lid. DC 2 then continued to prepare the cooked food items on the steam table. DC 2 continued the same practice of not performing hand hygiene after each in direct contact with the trash lid with his bare hands on multiple occasions while preparing the cooked food items for lunch tray line. In a concurrent interview, DC 2 was asked when should he perform hand hygiene during the food preparation. DC 2 stated he should have washed his hands after each time he touched the trash lid to discard the trash. In a concurrent interview with DC 1, he stated DC 2 should have washed his hands after each contact with an unclean equipment or surface during the food preparation. On September 27, 2018, at 9:58 a.m., the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 136 of 140 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 10/01/2018 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 Dietary Supervisor (DS) was interviewed. The DS stated during food preparation, the DC should wash their hands every time they leave the cooking area or touch unclean equipment or surface to prevent the contamination of cooked food for the residents. The facility's policy andprocedure titled, "SANITATION AND INFECTION CONTROL...HANDWASHING," dated July 6, 2018, was reviewed. The policy indicated, "FREQUENCY...After handling carts, soiled dishes and utensils...Before and after doing cleaning procedures...Before and after handling foods...After handling any waste or waste products...After engaging in any activities that contaminate the hands..."

F867 SS=H QAPI/QAA Improvement Activities CFR(s): 483.75(g)(2)(ii)

F867 10/28/2018 §483.75(g) Quality assessment and assurance. §483.75(g)(2) The quality assessment and assurance committee must: (ii) Develop and implement appropriate plans of action to correct identified quality deficiencies; This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to set priorities for performance improvement activities that focus on high-risk, high volume, problem prone areas, when the facility failed to identify quality deficiencies related to medication availability. In addition, the facility failed to develop and implement action plans to correct identified qaulity deficiencies related to the unavailability of medication for the residents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 137 of 140 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 10/01/2018 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 This failure resulted in multiple residents not receiving their prescribed medications that could result to ineffective treatment of medical condition that could affect the overall well-being of the residents. (Refer to F684, F755, F760) Findings: On September 26, 2018, the survey team identified 33 residents had not reveived their prescribed medications as ordered due to medication unavailability from the period of August 2018 to September 2018. (Refer toF684, F755, F760). Quality deficiencies were identified related to medications availability in the facility. In addition, the facility failed to develop and implement an action plan to correct and identify quality deficiencies related to unavailability of medications for the residents. On September 28, 2018, at 4:00 p.m., the Director of Nursing (DON) was interviewed. The DON stated the facility's pharmaceutical services for acquiring medications (new orders and refills) was impacted by the new change of medication refill order from cycle to on demand. DON further stated a breakdown was identified when there was no follow up evaluation of the effectiveness of inservices and staff education for this new changes, thus had resulted to delay in the delivery of residents medications. On October 1, 2018, at 4:05 p.m., the Administrator was interviewed. The Administrator stated the facility was not aware multiple residents did not receive their precribed medications on multiple occasions due to medication unavailability. The Administrator stated the facility had just investigated the cause and it was determined FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 138 of 140 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 10/01/2018 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 that the medication unavailability was a result of the licensed nurses not being able to request a refill of the prescribed medications in a timely manner. In addition, the Administrator had stated the licensed nurses should have notified the residents' physicians and informed them of the missed doses of the prescribed medications. The Administrator further stated the licensed nurses should have requested for refill medication for the residents five days before they had ran out. The Administrator stated this was not done and it had resulted to the delayed delivery of the medications to the residents causing the medication unavailabitliy. The Administrator stated the facility did not have an action plan on ensuring the system for medication refill request to the pharmacy would be processed efficiently to help prevent the delay of medication refill deliveries. The Administrator stated the QAPI committee reviewed the cause and analysis of why an issue is not working in the facility and they modify their objectives. He confirmed the issue of medications not being available to the residents should have been identified by the committee. A review of the facility's policy and procedure titled, "Quality Assurance and Performance Improvement (QAPI) Plan," revised July 6, 2018, was reviewed. The policy indicated, "The objectives of the QAPI plan are to provide a means to identify and resolve present and potential negative outcomes related to resident care and services...Provide structure and processes to correct identified quality and/or safety deficiencies..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B8UC11 Facility ID: CA240000723 If continuation sheet 139 of 140 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 10/01/2018 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) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: B8UC11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA240000723 (X5) COMPLETE DATE If continuation sheet 140 of 140