Other·July 18, 2017

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 an complaint. Complaint: CA00483247 Representing the California Department of Public Health: Surveyor Federal ID: 35229, 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 issued for complaint number CA00483247.

F226 SS=D DEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES CFR(s): 483.13(c)

F226 06/03/2016 The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to implement their policy and 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: FY5S11 Facility ID: CA250001382 If continuation sheet 1 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555742 (X3) DATE SURVEY COMPLETED 05/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DESERT MOUNTAIN CARE CENTER 47763 Monroe St Indio, CA 92201 (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 procedure for abuse investigation and reporting by ensuring: 1. Resident A's alleged abuse was investigated by the facility; and 2. Resident A's alleged abuse was reported to the California Department of Public Health, Ombudsman, and Local Enforcement Agency. These failures increased the potential for incidents of alleged abuse to not be reported and investigated timely and appropriately. Findings: On April 18, 2016, at 1:40 p.m. an unannounced visit was made to the facility to investigate a complaint of alleged abuse involving one facility staff on December 19, 2015, when Resident A reported an alleged incident of mistreatment by the facility staff. On April 18, 2016, Resident A's record was reviewed. Resident A was admitted to the facility on October 31, 2011, with diagnoses that included mood disorder and COPD (chronic obstructive pulmonary disease respiratory problem). A document titled, "Progress Notes - Initial Change of Condition - Emotional Distress," dated December 19, 2015, indicated, "Pt (Patient) reported to this writer that previously assigned CNA 1 (Certified Nursing Assistant 1) had mistreated her, pt noted to be upset. full body check completed, noted small dime size redness to right index finger, no swelling noted not warm to touch, pt stated redness due to urine cylinder (a container to measure a urine)... abuse coordinator made aware..." On April 18, 2016, at 1:50 p.m., an interview FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FY5S11 Facility ID: CA250001382 If continuation sheet 2 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555742 (X3) DATE SURVEY COMPLETED 05/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DESERT MOUNTAIN CARE CENTER 47763 Monroe St Indio, CA 92201 (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 Resident A. Resident A was able to recalled the alleged incident on December 19, 2015. Resident A stated, it happened during the time when the CNA was providing care to her, CNA 1 hit her on the hand with the urine cylinder. She further stated, "He hit me." On April 18, 2016, at 2:10 p.m., a second interview was conducted to Resident A. Resident A stated, the CNA 1 hit her during the time he was giving care to her. Resident A further stated the CNA 1 who hit her was no longer working at the facility. A review of Resident A's Minimum Data Set (MDS - an assessment tool), dated December 29, 2015, indicated, Resident A was assessed as: "Brief Interview for Mental Status (BIMS) Summary Score: 15 total score (0-15 with 15 score a higher level of memory recall)." On April 18, 2016, at 2:25 p.m., an interview was conducted with the Administrator and Director of Nursing (DON) regarding the alleged abuse. The Administrator stated the incident of alleged abuse was not reported to the California Department of Public Health, Ombudsman, and Local Enforcement Agency. The incident of alleged abuse was not reported to the California Department of Public Health, Ombudsman, and Local Enforcement Agency per facility's policy and procedure. On April 20, 2016, at 12:32 p.m., the Social Service Director (SSD) was interviewed, and stated she reviewed Resident A's record and was not able to find documentation regarding the alleged abuse incident reported to have happen on December 19, 2015. There was no indication that an investigation of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FY5S11 Facility ID: CA250001382 If continuation sheet 3 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555742 (X3) DATE SURVEY COMPLETED 05/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DESERT MOUNTAIN CARE CENTER 47763 Monroe St Indio, CA 92201 (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 alleged incident was conducted by the facility. On April 18, 2016, the facility's policy and procedure titled, "Abuse and Neglect Prohibition Policy," updated on January 1, 2013 were reviewed. The policy indicated: "Policy. It is the policy of (Facility Name) to ensure that violations by anyone in the facility involving mistreatment, neglect, or abuse of any kind, including injuries of an unknown source, or intentional misappropriation of resident property are reported immediately to the abuse coordinator within 24 hours. The facility administrator will report all allegations of abuse to the state in accordance with state law. ...E. Investigation. 1. The facility will conduct an investigation of an alleged abuse/neglect or misappropriation of resident property in accordance with state law. 2. The facility will report such allegations to the state, as per state regulation. 3. The facility will report all investigation findings to the state as per state regulations ...G. Reporting and Response. 1. The facility will report all allegations and substantiated occurrences of abuse, neglect, and misappropriation of property to the state agency and law enforcement officials as designed by state law... 3. The facility will report any occurrences of abuse by registered or certified staff to the State Board as required by state law... 5. As of January 1, 2013, AB40 requires all mandated reporters who reasonable suspect or have observed physical abuse of an elder or dependent adult to report all instances to the local ombudsman in addition to local enforcement and the Department of Public Health..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FY5S11 Facility ID: CA250001382 If continuation sheet 4 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555742 (X3) DATE SURVEY COMPLETED 05/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DESERT MOUNTAIN CARE CENTER 47763 Monroe St Indio, CA 92201 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F279 DEVELOP COMPREHENSIVE CARE PLANS CFR(s): 483.20(d), 483.20(k)(1)

F279 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 06/03/2016 A facility must use the results of the assessment to develop, review and revise the resident's comprehensive plan of care. The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.25; and any services that would otherwise be required under §483.25 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(b)(4). This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure a care plan was developed and implemented after Resident A's alleged incident of mistreatment and emotional distress. This failed practice increased the potential for Resident A's emotional distress to continue without being addressed by the facility. Findings: On April 18, 2016, at 1:40 p.m. an unannounced visit was made to the facility to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FY5S11 Facility ID: CA250001382 If continuation sheet 5 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555742 (X3) DATE SURVEY COMPLETED 05/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DESERT MOUNTAIN CARE CENTER 47763 Monroe St Indio, CA 92201 (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 investigate a complaint of alleged abuse involving one facility staff member on December 19, 2015, when Resident A reported an alleged incident of mistreatment by the facility staff. On April 18, 2016, Resident A's record was reviewed. Resident A was admitted to the facility on October 31, 2011, with diagnoses that included mood disorder and COPD (chronic obstructive pulmonary disease - a respiratory problem). A document titled, "Progress Notes - Initial Change of Condition - Emotional Distress," dated December 19, 2015, indicated, "Pt (Patient) reported to this writer that a previously assigned CNA 1 (Certified Nursing Assistant 1) had mistreated her, pt noted to be upset. full body check completed, noted small dime size redness to right index finger, no swelling noted not warm to touch, pt stated redness due to urine cylinder (a container to measure a urine)... abuse coordinator made aware..." On April 18, 2016, at 1:50 p.m., an interview was conducted with Resident A. The resident was able to recalled the alleged incident on December 19, 2016. Resident A stated, during the time when the CNA 1 was providing care to her, CNA 1 hit her on the hand with the urine cylinder. She further stated, "He hit me." On April 18, 2016, at 2:10 p.m., a second interview was conducted with Resident A. The Resident stated the CNA 1 hit her during the time he was giving care to her. Resident A further stated the CNA 1 who hit her was no longer working at the facility. A review of Resident A's Minimum Data Set (MDS - an assessment tool), dated December 29, 2015, indicated Resident A was assessed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FY5S11 Facility ID: CA250001382 If continuation sheet 6 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555742 (X3) DATE SURVEY COMPLETED 05/17/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DESERT MOUNTAIN CARE CENTER 47763 Monroe St Indio, CA 92201 (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 as: "Brief Interview for Mental Status (BIMS) Summary Score: 15 total score (0-15 with 15 score a higher level of memory recall)." On April 18, 2016, at 2:25 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated that he was not able to find a care plan for Resident A's, "Initial Change of Condition - Emotional Distress." He further stated the care plan was not done. On April 18, 2016, an undated/ untitled facility policy and procedure was reviewed. The policy indicated, "Policy: It is the policy of (Facility Name) to meet the residents needs with the development and maintenance of an individualized care plan. ...The care plan is modified as needed to reflect change in condition, treatment, or resident and family input." Resident A reported an alleged incident of abuse and had documented incidents of distress. The facility failed to address those incidents with a care plan aimed to diminish the resident's distress. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FY5S11 Facility ID: CA250001382 If continuation sheet 7 of 7