Other·October 6, 2020

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated standard survey for the investigation of one complaint. Complaint number CA00655276 Representing the California Department of Public Health: Surveyor Federal ID Number 33235, HFEN. The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Two deficiencies were isued for Complaint number CA00655276.

F583 SS=D Personal Privacy/Confidentiality of Records CFR(s): 483.10(h)(1)-(3)(i)(ii)

F583 12/19/2019 §483.10(h) Privacy and Confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. §483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. §483.10(h)(2) The facility must respect the residents right to personal privacy, including 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: VKS911 Facility ID: CA240000723 If continuation sheet 1 of 16 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 11/19/2019 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 right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service. §483.10(h)(3) The resident has a right to secure and confidential personal and medical records. (i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws. (ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to protect confidential personal and medical information of one resident (Resident 2) out of five residents surveyed. This failure resulted in access by unauthorized individuals of protected information for Resident 2. Findings: On October 1, 2019, at 10:15 a.m., an unannounced visit was made to the facility to investigate a complaint regarding quality of care. On October 1, 2019, a review of the facility medical record for Resident 1 was conducted. Resident 1 was a 70 year old male, who was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VKS911 Facility ID: CA240000723 If continuation sheet 2 of 16 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 11/19/2019 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 on September 12, 2018, with diagnoses including hemiplegia (paralysis) following a non-traumatic subarachnoid hemorrhage (stroke) affecting his right side. A Facility Observation Detail List report, dated September 17, 2019, at 1:07 a.m., indicated Resident 1, on the evening of September 16, 2019, fell while in the bathroom. The Certified Nursing Assistant (CNA 1) found him on his knees on the floor. He was assessed and no injury was found. The resident was assisted back to bed. This report further indicated, "...around 7:30 pm resident already on bed have a large yellow vomiting and seeing he aspirated validated by noted (sic) auscultation and congestion, ...resident then ALOC (altered level of consciousness) and not responding to any stimuli, decided to call paramedic for transfer and treatment." On October 1, 2019, a review of the facility medical record for Resident 2 was conducted. Resident 2 was a 61 year old male, admitted to the facility on Sept 9, 2019, with diagnoses including cellulitis of right upper limb (infection of upper right arm), chronic kidney disease, and shortness of breath. Resident 2 was never sent to the emergency department. On October 1, 2019, the medical record from the acute care facility for Resident 2 was reviewed: The Patient Care Report, dated September 16, 2019, with time starting at 9:10 p.m., from the EMS (Emergency Medical Service) Unit indicated the name of Resident 2. The Narrative section indicated, "..PT (patient) was (sic) had a fall approx. (approximately) 2 hours FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VKS911 Facility ID: CA240000723 If continuation sheet 3 of 16 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 11/19/2019 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 PTA (prior to arrival)." The narrative described the history of Resident 1. A Face Sheet for Resident 2 from the facility that was dated as being printed on September 16, 2019, at 4:40 p.m., was with the the Patient Care Report noted above. A faxed Physician Order Report from Monterey Palms with the name of Resident 2 was reviewed. The fax indicated it was sent on September 16, 2019, at 11:08 p.m., from the fax phone number of the facility to the emergency room. On October 1, 2019, at 10:15 a.m., an interview was conducted with the Director of Nurses (DON). The DON stated the nurse sent the "majority" of correct information for Resident 1. When asked what she meant by "majority", the DON stated, "It was all his information, medications, face sheet, POLST, maybe something else slipped in there." The DON stated the nurse should have double checked to sure he sent all the correct information. On October 1, 2019, at 1:01 p.m., a phone interview was conducted with Registered Nurse (RN 1). RN 1 stated he printed the copies of the Face Sheet, POLST, and Dr. Orders for Resident 1 to have them ready for the paramedics. He stated he gave the paperwork to Licensed Vocational Nurse (LVN 1). RN 1 stated, "A nurse called me from the Emergency Department (ED) and asked me to send the Doctor's Orders for the resident we had just sent over." RN 1 stated he sent over FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VKS911 Facility ID: CA240000723 If continuation sheet 4 of 16 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 11/19/2019 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 1's Doctor Orders. RN 1 stated he got a second call from the ED and was asked to send the Doctor Orders for Resident 2. RN 1 stated he told the nurse that he had not sent Resident 2 to the ED. RN 1 stated to the best of his knowledge he never sent any information on Resident 2, but maybe something slipped in there. On October 1, 2019, at 2:22 p.m., an interview was conducted with Registered Nurse Quality Management (QMRN). QMRN stated, "Initially the name of (Resident 2's name) was on all the documentation in our medical record. QMRN stated, "We changed the name to (Resident 1's name) once we had the correct identification." QMRN stated the paramedic report remained in (name of Resident 2) because they were unable to change it. QMRN stated as a result of the misidentification the wrong next of kin was contacted and there was a delay in contacting the correct emergency contact. QMRN stated the care for Resident 1 was compromised because the platelets (a blood product) could not be released due to the blood mismatch. It was not until around 8 a.m., the following morning that the correct identification of Resident 1 was made. On October 2, 2019, at 9:15 a.m., a phone interview was conducted with Paramedic (P1). P1 stated he was one of the paramedics responding to the facility the night of September 16, 2019, for (name of Resident 1). He stated they went to his room and began an assessment, He stated his co-worker, Paramedic (P2), began entering the (name of Resident 2) information into their computer using the information handed to them by one of the nurses. P2 stated they use the Face sheet from the facility to enter the resident's name FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VKS911 Facility ID: CA240000723 If continuation sheet 5 of 16 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 11/19/2019 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 other preliminary information like his birth date into the computer. P1 stated they were unaware that the facility had handed them the medical record document for Resident 2 and not Resident 1. P1 stated he does not remember the nurses at the facility giving them any information verbally about Resident 1 or mentioning his name. P1 stated when they brought the resident to the emergency room, he was in the room with (name of Resident 1) and Emergency Department Registered Nurse (EDRN 1). He gave the medical record information from the facility to EDRN 1. The medication list was not there. P1 stated that EDRN 1 called the facility and asked for the medication list of (name of Resident 2) to be sent to (name of acute care facility). On October 3, 2019, at 3:12 p.m., a phone interview was conducted with EDRN 1. EDRN 1 stated he was the nurse receiving (name of Resident 1) on the night of September 16, 2019. EDRN 1 stated he was given a packet from the paramedics with a face sheet and a POLST (Physician Orders for Life Sustaining Treatment- indicates whether the resident wanted full resuscitation or not in the event of he had no pulse or was not breathing). EDRN 1 stated both the Face Sheet and the POLST had the (name of Resident 2). EDRN 1 stated there was no medication list. EDRN 1 stated it was important to have a medication list so they would know if the resident was on any blood thinners or any medications that would interact with any medications they would give him. The Doctor's orders are usually sent with the patient. EDRN 1 stated he called the facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VKS911 Facility ID: CA240000723 If continuation sheet 6 of 16 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 11/19/2019 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 talked to a nurse and asked that the Doctor Orders be faxed over for the patient (Resident 2). EDRN 1 stated he used the name of Resident 2. EDRN 1 stated the nurse at the facility did not give him any indication that Resident 2 was not the resident that had been sent. EDRN 1 stated within a few minutes they received the doctor's orders for Resident 2. On October 4, 2019, at 1:23 p.m., a phone interview was conducted with Licensed Vocational Nurse 1 (LVN 1). LVN 1 stated she was the nurse caring for Resident 1 the night he was sent to the hospital. LVN 1 stated she was a new nursing graduate and the other nurses working that night were helping her with the transfer. LVN 1 stated RN 1 made copies of the face sheet, POLST, and Doctor's Orders. RN 1 gave her the copies and she handed them to the paramedics when they arrived. On October 4, 2019, facility documentation of an interview with RN 1 dated September 17, 2019, indicated RN 1 stated he did send the medical documents of Resident 2 to the emergency department at the request of the EDRN. On October 4, 2019, the facility policy and procedure (P&P) titled, " Confidentiality/Security of InformationManual/Automated", and dated as revised on April 26, 2019, was reviewed. The P&P indicated, "All information, both automated and manual regarding specific residents...or related health information pertaining to a resident is protected by law and must be secured against loss, destruction and unauthorized access or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VKS911 Facility ID: CA240000723 If continuation sheet 7 of 16 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 11/19/2019 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 use."

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

F684 12/19/2019 § 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 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 interview and record review, the facility erroneously sent the wrong medical information of one resident (Resident 1) out of five residents surveyed, to the emergency room. This failure caused a delay in treatment for Resident 1, the wrong emergency contact to be notified by the emergency department, and a delay in notifying the correct emergency contact. Findings: On October 1, 2019, at 10:15 a.m., an unannounced visit was made to the facility to investigate a complaint regarding quality of care. On October 1, 2019, a review of the facility medical record for Resident 1 was conducted. Resident 1 was a 70 year old male, who was admitted on September 12, 2018, with diagnoses including hemiplegia (paralysis) following a non-traumatic subarachnoid hemorrhage (stroke) affecting his right side. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VKS911 Facility ID: CA240000723 If continuation sheet 8 of 16 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 11/19/2019 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 Facility Observation Detail List report, dated September 17, 2019, at 1:07 a.m., indicated Resident 1, on the evening of September 16, 2019, fell while in the bathroom. The Certified Nursing Assistant (CNA 1) found him on his knees on the floor. He was assessed and no injury was found. The resident was assisted back to bed. This report further indicated, "...around 7:30 pm resident already on bed have a large yellow vomiting and seeing he aspirated validated by noted (sic) auscultation and congestion, ...resident then ALOC (altered level of consciousness) and not responding to any stimuli, decided to call paramedic for transfer and treatment." On October 1, 2019, a review of the facility medical record for Resident 2 was conducted. Resident 2 was a 61 year old male, admitted to the facility on Sept 9, 2019, with diagnoses including cellulitis of right upper limb (infection of upper right arm), chronic kidney disease, and shortness of breath. Resident 2 was never sent to the emergency department. On October 1, 2019, the medical record from the acute care facility for Resident 1 was reviewed: The Patient Care Report, dated September 16, 2019, with time starting at 9:10 p.m., from the EMS (Emergency Medical Service) Unit indicated the name of Resident 2. The Narrative section indicated, "..PT (patient) was (sic) had a fall approx. (approximately) 2 hours PTA (prior to arrival)." The narrative describes the history of Resident 1. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VKS911 Facility ID: CA240000723 If continuation sheet 9 of 16 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 11/19/2019 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 Face Sheet for Resident 2 from the facility that was dated as being printed on September 16, 2019, at 4:40 p.m., was with the the Patient Care Report noted above. A faxed Physician Order Report from Monterey Palms with the name of Resident 2 was reviewed. The fax indicated it was sent on September 16, 2019, at 11:08 p.m., from the fax phone number of the facility to the emergency room. An ED Re-Eval Note, dated September 16, 2019, at 10:39 p.m., written by (name of physician) indicated the physician attempted to reach the emergency contact person for Resident 2. He left a message for them to call back. An ED Re-Eval Note, dated September 16, 2019, at 10:59 p.m., written by (name of physician) indicated the emergency contact for Resident 2 called back and she stated Resident 2 had multiple medical problems. She wanted to wait until the morning to make final decision regarding continuation of care. Provider Notification dated September 16, 2019, at 6:32 a.m., indicated, " MD (Medical Doctor) notified that patient has not gotten the ordered unit of platelets (a blood product) as there is a discrepancy in patients' blood type according to the blood sent earlier. Infusion services states patient has been blood type O negative in the past, new blood draw reads O positive. Unable to administer platelets because of this ..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VKS911 Facility ID: CA240000723 If continuation sheet 10 of 16 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 11/19/2019 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 Nursing Note dated September 17, 2019 , at 9:44 a.m., written by (name of hospital Registered Nurse) indicated, " ...(name of POA [power of Attorney- person designated to make medical decisions for resident] for Resident 2) notified at (phone number) regarding the fact that (name of Resident 2) is at (name of facility), and the patient we currently have in ICU (Intensive Care Unit) is a different resident from (name of facility)." A Social Worker Progress note, dated September 17, 2019, indicated, "SW (social worker) was informed by bedside RN (Registered Nurse 1) (name of nurse) regarding incorrect identifying information for this patient what was received from (name of facility). Per RN, there were two different records provided at time of admission with different names. The pt (patient) was originally believed to be (Name of Resident 2), however, it was found that (name of Resident 2) remains a patient at (name of facility) and this pt was identified as (name of Resident 1) by ICU (Intensive Care Unit) RN Director (name of director)." The emergency contact for Resident 1 was contacted at 9:32 a.m., by SW, the emergency contact stated she had been notified of the misidentification, "SW provided her with emotional support as she was tearful." On October 1, 2019, at 10:15 a.m., an interview was conducted with the Director of Nurses (DON). The DON stated the nurse sent the "majority" of correct information for Resident 1. When asked what she meant by "majority," the DON stated, "It was all his information, medications, face sheet, POLST, maybe something else slipped in there." The DON stated the nurse should have double checked to sure he sent all the correct FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VKS911 Facility ID: CA240000723 If continuation sheet 11 of 16 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 11/19/2019 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 information. On October 1, 2019, at 1:01 p.m., a phone interview was conducted with Registered Nurse (RN 1). RN 1 stated he printed the copies of the Face Sheet, POLST, and Dr. Orders to have them ready for the paramedics. He stated he gave the paperwork to Licensed Vocational Nurse (LVN 1). RN 1 stated, "A nurse called me from the Emergency Department (ED) and asked me to send the Doctor's Orders for the resident we had just sent over." RN 1 stated he sent over Resident 1's Doctor Orders. RN 1 stated he got a second call from the ED and was asked to send the Doctor Orders for Resident 2. RN 1 stated he told the nurse that he had not sent Resident 2 to the ED. RN 1 stated to the best of his knowledge he never sent any information on Resident 2, but maybe something slipped in there. On October 1, 2019, at 2:22 p.m., an interview was conducted with Registered Nurse Quality Management (QMRN). QMRN stated, "Initially the name of (Resident 2's name) was on all the documentation in our medical record," QMRN stated, "We changed the name to (Resident 1's name) once we had the correct identification." QMRN stated the paramedic report remained in (name of Resident 2) because they were unable to change it. QMRN stated as a result of the misidentification the wrong next of kin was contacted and there was a delay in contacting the correct emergency contact. QMRN stated the care for Resident 1 was compromised because the platelets could not be released due to the blood mismatch. It was not until around 8 a.m., the following FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VKS911 Facility ID: CA240000723 If continuation sheet 12 of 16 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 11/19/2019 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 morning that the correct identification of Resident 1 was made. On October 2, 2019, at 9:15 a.m., a phone interview was conducted with Paramedic 1 (P1). P1 stated he was one of the paramedics responding to the facility the night of September 16, 2019, for Resident 1. He stated they went to his room and began an assessment, He stated his co-worker, Paramedic 2 (P2), began entering the resident's (Resident 1) information into their computer using the information handed to them by one of the nurses. P2 stated they use the Face sheet from the facility to enter the resident's name and other preliminary information like his birth date into the computer. P1 stated they were unaware that the facility had handed them the medical record document for Resident 2 and not Resident 1. P1 stated he does not remember the nurses at the facility giving them any information verbally about Resident 1 or mentioning his name. P1 stated when they brought the resident to the emergency room, he was in the room with Resident 1 and Emergency Department Registered Nurse (EDRN 1). He gave the medical record information from the facility to EDRN 1. The medication list was not there. P1 stated that EDRN 1 called the facility and asked for the medication list of Resident 2 to be sent to (name of acute care facility). On October 3, 2019, at 3:12 p.m., a phone interview was conducted with EDRN 1. EDRN 1 stated he was the nurse receiving Resident 1 on the night of September 16, 2019. EDRN 1 stated he was given a packet from the paramedics with a face sheet and a POLST FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VKS911 Facility ID: CA240000723 If continuation sheet 13 of 16 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 11/19/2019 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 (Physician Orders for Life Sustaining Treatment- indicates whether the resident wanted full resuscitation or not in the event of he had no pulse or was not breathing). EDRN 1 stated both the Face Sheet and the POLST had the name of Resident 2. EDRN 1 stated there was no medication list. EDRN 1 stated it was important to have a medication list so they would know if the resident was on any blood thinners or any medications that would interact with any medications they would give him. The Doctor's orders are usually sent with the patient. EDRN 1 stated he called the facility and talked to a nurse and asked that the Doctor Orders be faxed over for the patient (Resident 2). EDRN 1 stated he used the name of Resident 2. EDRN 1 stated the nurse at the facility did not give him any indication that Resident 2 was not the resident that had been sent. EDRN 1 stated within a few minutes they received the Dr. orders for Resident 2. EDRN 1 stated, "The doctor continued to work him up and ordered a CT scan, labs, the patient was intubated, and we sent him to ICU. The whole time we thought he was Resident 2." On October 4, 2019, at 1:23 p.m., a phone interview was conducted with Licensed Vocational Nurse 1 (LVN 1). LVN 1 stated she was the nurse caring for Resident 1 the night he was sent to the hospital. LVN 1 stated she was a new nursing graduate and the other nurses working that night were helping her with the transfer. LVN 1 stated RN 1 made copies of the face sheet, POLST, and Doctor's Orders. RN 1 gave her the copies and she handed them to the paramedics when they arrived. LVN 1 stated she had not taken care of Resident 1 before, so she had no history to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VKS911 Facility ID: CA240000723 If continuation sheet 14 of 16 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 11/19/2019 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 report to the paramedics. LVN 1 stated LVN 2 came to help her because she knew Resident 1 better. She did not remember the name of Resident 1 being mentioned to the paramedics. On October 4, 2019, an interview was conducted with Licensed Vocational Nurse (LVN 2). LVN 2 stated she came to help with the transfer because she had taken care of Resident 1 several times in the past. She stated usually the nurse would use the face sheet to give the paramedics a history of the resident. LVN 2 stated because she knew Resident 1, she was able to give the history without referring to the face sheet. LVN 2 did not recall using Resident 1's name when talking to the paramedics. On October 4, 2019, facility documentation of an interview with RN 1 dated September 17, 2019, indicated RN 1 stated he did send the medical documents of Resident 2 to the Emergency Department at the request of the EDRN. On October 9, 2019, at 10 a.m., a phone interview was conducted with the ADM. The ADM was asked about the facility policy regarding the residents wearing identification bracelets. The ADM stated it was their policy that each resident does wear an identification bracelet. The ADM was asked if Resident 1 was wearing an identification bracelet. The ADM stated in their investigation, the licensed staff were unable to verify Resident 1 wore an identification bracelet, but one Certified Nursing Assistant stated he saw an identification bracelet on Resident 1. On October 28, 2019, at 3:15 p.m., an interview FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VKS911 Facility ID: CA240000723 If continuation sheet 15 of 16 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 11/19/2019 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 conducted with QMRN. QMRN stated in their investigation, they found (name of Resident 1) was not wearing an identification bracelet when he arrived in the emergency room. On November 14, 2019 the facility policy and procedure (P&P), titled,"Resident Identification System", and dated December 18, 2002, was reviewed. The P&P indicated, "...The following systems assist the facility personnel to correctly identify residents: a. identification bracelet (required, not an option)..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VKS911 Facility ID: CA240000723 If continuation sheet 16 of 16