Health inspection·August 19, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few AMA and that this was a letter stating her wishes of leaving and that patient was fully aware that she was leaving against medical advice. I proceeded to ask her if her (Resident 1's) nurse was aware and that there was a facility form that we needed patient to sign, she then informed me patient was already gone, the lady walked away . On August 18, 2025, at 4:26 p.m., an interview was conducted with LVN 1. LVN 1 stated that the process for a resident to leave AMA from the facility includes trying to encourage the resident to stay, notifying the physician, receiving orders, and having the resident sign an AMA form prior to the discharge. LVN 1 stated on August 9, 2025, at approximately 5:30 p.m., she was working in the nurse's station, when a woman she had never seen before, approached her and handed her a note stating Resident 1 is leaving AMA. LVN 1 stated she told the woman there is a form Resident 1 needed to sign, and the woman stated Resident 1 had already left the facility, and the woman turned and walked away. LVN 1 stated she immediately notified Resident 1's assigned nurse. LVN 1 stated she was not aware of RR 2's concerns of Resident 1 possibly leaving AMA during visits with Resident 1's FM. LVN 1 stated she did not follow the unknown women out of the facility to search for Resident 1, stating I guess I could have, but I was taken aback (surprised) at the moment. A review of the note given to LVN 1, dated, August 9, 2025, untimed, indicated, I (Resident 1) on this 9th day of August 2025 called (FM) to come pick me up because I want to go home . I'm aware that I am leaving against medical advice. The note had Resident 1's name as a signature and another unknown person as the witness. On August 18, 2025, at 4:43 p.m., an interview was conducted with LVN 2, who stated, on August 9, 2025, at approximately 5:30 p.m., LVN 1 notified her that an unknown woman gave LVN 1 a note stating Resident 1 wanted to leave AMA. LVN 2 stated when the resident's letter was given to LVN 1, the resident had already left the building. LVN 2 stated LVN 1 did not get any other information from the unknown woman. LVN 2 stated she looked for Resident 1 in her room and inside the facility and asked CNA 2 if he saw a resident leave the facility. CNA 2 stated he did not witness the resident leave the facility, and the last time CNA 2 saw the resident was at approximately 3:30 p.m. LVN 2 verified she did not ask CNA 2 to look outside the facility for Resident 1, stating, That's something we could have done. On August 18, 2025, at 5:15 p.m., an interview was conducted with the Director of Nursing (DON), who stated, RR 2's concerns about Resident 1 discharging from the facility AMA with her FM was an ongoing discussion during the morning huddles (a daily meeting with the department managers and day shift charge nurses). The DON stated clinical managers were expected to pass the information from the huddles on to all nursing staff. On August 18, 2025, at 5:30 p.m., an interview was conducted with LVN 1. LVN 1 stated she was unaware of RR 2's concerns that Resident 1's FM might try to get the Resident to leave AMA. On August 19, 2025, at 2:47 p.m., an interview was conducted with CNA 2. CNA 2 stated he was Resident 1's assigned CNA on August 9, 2025, the evening Resident 1 left the facility. CNA 2 stated, on that day, he took Resident 1's vital signs (Blood Pressure, pulse, temperature & respirations) at approximately 3:30 p.m., and the resident was in her room alone. CNA 2 stated when he returned to the resident's room at approximately 4:30 p.m., Resident 1 was no longer in her room. CNA 2 stated he searched the unit for Resident 1, but did not search the outside grounds. On August 19, 2025, at 3:24 p.m., an interview was conducted with the DON, who stated it is her expectation of nursing staff to monitor the residents' whereabouts every hour. The DON stated she was not sure how Resident 1 left the facility unwitnessed by staff. On August 19, 2025, at 4:00 p.m., an interview was conducted with the Admin, who stated, she did not talk to Resident 1 regarding her representative's concerns that she may leave AMA with another FM. The Admin stated she could have explained to Resident 1 that she has the right to leave the facility AMA, but notify staff first. The Admin stated Resident 1 may have been able to leave the unit without staff's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555226 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555226 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Springs Healthcare Center at the Carlotta 41505 Carlotta Drive Palm Desert, CA 92211 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm knowledge, by strolling around, without a lot of belongings, and that Resident 1 probably did not look like she was leaving the facility. A facility Policy & Procedure, titled, Safety and Supervision of Resident, revised, July 2017, indicated, . Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The care team shall target interventions to reduce individual risks . including adequate supervision . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555226 If continuation sheet Page 3 of 3