California Nursing & Rehabilitation Center

F-F692), kitchen and nutrition services (see findings under

F-F803

During a review of the facility's Winter Menu, Week 4, the Tuesday 2/25/25 lunch meal for the Regular diet included 3oz (ounces) of herb crusted beef roast, 1/2 oz brown gravy, 1/2 cup mashed potatoes, 1/2 cup zesty spinach, parsley sprig garnish, 1 slice of garlic bread, and 1 Sq. (square) triple fruit crisp. The pureed (food made into a creamy substance) meal included 1/2 cup pureed herb crusted beef roast, 1/3 cup mashed potatoes, 1/3 cup zesty spinach, 1/4 cup garlic bread, and 1/3 cup triple fruit crisp.

On February 24, 2025, at 9:32 a.m., a Resident Council meeting was conducted. During the meeting, multiple residents anonymously stated the food is served cold.

On February 24, 2025, at 11:06 a.m., an interview with Resident 18 was conducted. Resident 18 stated the breakfast meals are cold almost every day.

On February 24, 2025, at 12:45 p.m., a concurrent interview and test tray evaluation of the Regular and Pureed diets was conducted. The Diet Service Manager/Registered Dietitian's (DSM-RD) facility's thermometer did not obtain the correct food temperatures on the test tray. The facility thermometer read 118 degrees F (fahrenheit) for the puree roast beef, and it was 125.3 degrees F on the Surveyor's thermometer.

The facility's thermometer read 121.1 degrees F for the regular roast beef, and it was 121 degrees F on the Surveyor's thermometer. The facility's thermometer read 56.0 degrees F on the orange juice and 50.6 degrees F on the Surveyor's thermometer. When the regular diet spinach was tasted, it had no flavor, and

the potato wedges were hard. Furthermore, garlic bread was dried out and hard to chew. The DSM-RD acknowledged the spinach needed more flavor, the potato wedges had hard ends, and the garlic bread was tough to eat. The DSM-RD further stated we need to do a better job with seasoning and cooking temperatures.

Review of facility policy and procedure titled, Food Temperatures dated October 10, 2023, indicated, .it is recommended to use a thermometer with a practical range of 0 (degrees) F to 220 F . acceptable serving temperatures for Meat, entrees are > (greater than) 140 and preferable temperature is 160 -175 and for Milk, juice temperature required are < (less than) 41 .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 67 056428 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056428 B. Wing 03/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

California Nursing & Rehabilitation Center 2299 North Indian Canyon Drive Palm Springs, CA 92262

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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 49113

Residents Affected - Many Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation practices were maintained in the kitchen according to standards of practice and facility policy when:

1. The ice machine was not properly maintained and cleaned per manufacturer guidelines;

2. The dish machine sanitizer solution was outside of the correct chemical range and tested 300- 400 ppm (parts per million- a unit of measurement);

3. Kitchen staff did not wear beard nets while working in the kitchen;

4. Dishes and three (3) large metal pans with food debris and dripping water on them were stacked on top of each other in a drawer; and

5. Kitchen staff were using cloth oven mitts that were wet, soiled, and had food build-up/residue on them.

These failures exposed resident's to contaminated food and unsanitary practices, which placed residents at risk of developing foodborne illness and compromise their health. The facility census was 72.

Cross reference

F-F812

Findings:

1. During a review of The Academy of Nutrition and Dietetics Evidence Analysis Library regarding Unintended Weight Loss for Older Adults Evidence-Based Nutrition Practice Guidelines, dated 2007-2009, .

The Registered Dietitian should monitor and evaluate weekly body weights of older adults with unintended weight loss, until body weight has stabilized, to determine effectiveness of medical nutrition therapy (MNT) .

During the facility's recertification survey from 2/24/25 - 3/3/25, multiple observations, interviews and record reviews were conducted with residents and staff and a sample of five residents (23, 43, 51, 58 and 673) were found to have experienced severe, unintentional and unplanned weight losses within three months, which led to an immediate jeopardy being called.

a) Resident 23 experienced a severe unplanned weight loss of 16 lbs. (pounds- a measurement of weight), 8. 04% from the weights obtained on 11/5/24 to 2/26/25. Resident 23 was diagnosed with uncontrolled diabetes mellitus (condition in which the body has trouble controlling blood sugar). The resident was not placed on weekly weights, the Registered Dietitian (RD) did not reassess the resident to determine appropriate interventions to address the weight loss, and the weight loss was not communicated to the Physician.

b) Resident 43 experienced a severe unplanned weight loss of 14 lbs. or 11.67% from the weights obtained

on 11/5/24 to 2/7/25. Resident 43 was diagnosed with hyperlipidemia (elevated blood fat levels) and a body mass index (BMI) of 16.5 (less than 18 is underweight). The resident was not placed on weekly weights, the RD did not reassess the resident to determine appropriate weight loss interventions, and the weight loss was not communicated to the Physician.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 67 056428 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056428 B. Wing 03/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

California Nursing & Rehabilitation Center 2299 North Indian Canyon Drive Palm Springs, CA 92262

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 0801 c) Resident 51 experienced a severe unplanned weight gain of 16 lbs., 10.26% from the weights obtained on 11/5/24 to 2/7/25. Resident 51 was diagnosed with hypothyroidism (condition which the thyroid gland does Level of Harm - Minimal harm or not produce enough thyroid hormone) and chronic kidney failure (CKD) (when the kidneys cannot filter potential for actual harm waste). Weekly weights were not implemented for the resident and the weight loss was not addressed by the Physician. Residents Affected - Many d) Resident 58 experienced a severe unplanned weight loss of 23 lbs., 12.3% from the weights obtained on 12/24/24 to 2/20/25. The resident was not reassessed by the RD to determine appropriate interventions, and

the Physician did not address the weight loss.

e) Resident 673 experienced a severe unplanned weight loss of 8.6 lbs., 5.78% from the weights obtained on 11/5/24 to 2/6/25. Resident 673 was diagnosed with dysphagia (difficulty swallowing) and hemiplegia (paralysis of one side of the body). The RD did not reassess the resident to address the severe weight loss to determine if the interventions were effective to prevent further weight loss.

During an interview with the facility's Registered Dietitian (RD) on 2/24/25 at 4:53 PM, the RD stated she recently became the full-time Dietary Services Manager a few weeks ago but previously worked at the facility as a clinical RD part-time, up to 20 hours a week. The RD stated since she has been the full-time DSW, she spent 70% to 75% of her time on clinical nutrition care and 25% to 30% of time on food service tasks.

During an interview on 2/27/25 at 4:05 PM with the RD-C (Corporate Registered Dietitian), the RD-C stated her expectation is for the facility's Dietitian to reassess the resident's weight history, clinical conditions, person-centered care plans, a calculated goal weight, and lab values to make nutrition recommendations and set goals to prevent further weight loss. The RD-C stated this information should be documented in the resident's medical chart for members of the IDT to view what the resident's nutrition goals are to prevent weight loss.

During an interview on 2/27/25 at 5:19 PM with the Director of Nursing (DON) about residents' weight loss,

the DON stated residents with significant or severe weight loss should be addressed with appropriate interventions by the RD, physician, nursing and IDT, according to the facility's policy.

During an interview on 3/3/25 at 12:18 PM with the medical director (MDR), the MDR stated the facility needs to make sure there are no 15-pound weight losses experienced in one month and the policies and procedures be followed to prevent or avoid further weight loss. He stated physicians should be documenting how they address the resident's weight loss in the chart and to make sure the interventions are appropriate and the RDs are involved to address the weight loss. The MDR further stated weight is a very important component of a resident's medical and nutrition status because it helps them gain strength to fight off diseases.

During an interview on 3/03/25 at 3:29 PM with the DSM-RD, the DSM-RD stated it was important for resident weight loss issues to be appropriately addressed to ensure the care of the resident. The DSM-RD further stated all tools should be used including fortified diets, supplements and shakes, additional portions and possible appetite medications to help improve a resident's food intake and nutrition status and prevent more weight loss.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 67 056428 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056428 B. Wing 03/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

California Nursing & Rehabilitation Center 2299 North Indian Canyon Drive Palm Springs, CA 92262

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 0801 Review of the California Code, Business and Professions Code - BPC S 2586, section (a)(1) indicated .a registered dietitian .may, upon referral by a health care provider authorized to prescribe dietary treatments, Level of Harm - Minimal harm or provide nutritional and dietary counseling, conduct nutritional and dietary assessments, and develop and potential for actual harm recommend nutritional and dietary treatments, including therapeutic diets, for individuals or groups of patients in licensed institutional facilities . The referral for medical nutrition therapy shall be accompanied by Residents Affected - Many a written prescription signed by the health care provider detailing the patient's diagnosis and including either

a statement of the desired objective of dietary treatment or a diet order may .initiate nutritional interventions within the parameters of the prescribed diet order .shall collaborate with a multidisciplinary team, which shall include the treating physician and the registered nurse, in developing the patient's nutrition care plan.may individualize the patient's nutritional or dietary treatment, when necessary, by modifying the distribution, type, or quantity of food and nutrients within the parameters of the diet order. Any modification, and the rationale for the modification, shall be documented in the patient's record for review by the practitioner, or other licensed health care professional .

2. During the facility's recertification survey from 2/24/25 - 3/3/25 multiple observations, interviews, and

record reviews were conducted regarding the facility's Diet Manual and following the facility's menus for renal diets.

a) On 2/26/25 at 8:32 AM at the Nursing Station, a record review of the facility's Diet Manual titled Diet Manual for Long Term Care and Residential Facilities 2020 was conducted. The Diet Manual indicated This manual has been evaluated and approved by the Patient Care Policy Committee of CNRC dated 1/8/20 . signed by a facility's registered dietitian and medical director (MDR).

During a concurrent interview and record review on 3/3/25 at 3:30 PM with the Dietary Services Manager-Registered Dietitian (DSM-RD), the DSM-RD acknowledged the facility's Diet Manual was not current or updated. The signature line for 2025 on the signature page titled Yearly Reviews was blank and not signed off by the RD and MDR. The DSM-RD stated it was important for the diet manual to be updated per regulation standards to ensure residents receive appropriate diets.

b) During a review of the facility's Cook's Spreadsheet Winter Menus- (Pg 2) the menu indicated .Week 1 . Tuesday .2/25/25, indicated .Renal Diets .Herb Crusted Beef Gravy 2 oz. meat, [NAME] with margarine #12 (1/3 cup), Zucchini with margarine 1/2 cup .Garlic Bread 1 slice .

During a review of the facility's Compact Roster by Name Report, dated 2/25/25, the report indicated Resident 66's diet was .Diet . Renal, CCHO (consistent carbohydrates), Fluid Restriction 1500 mL (milliliters) per day, Lactose (milk sugar) Free .80 gram and indicated Resident 17's diet was .Renal 60 gram-Regular-Large .

During an observation and interview on 2/25/25 at 11:59 A.M. of the lunch meal trayline service, [NAME] (CK 1) stated a renal diet meal tray would get .herb chicken, white rice, and zucchini . CK 1 stated they didn't have brown rice to serve and white rice is the same as brown rice.

On 2/26/25 at 2:46 P.M., an interview was conducted with the Dietary Services Manager-Registered Dietitian (DSM-RD). The DSM-RD stated it is her expectation that the Cooks and kitchen staff follow the printed menus, so the resident receives the appropriate diet and nutrition to meet their needs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 67 056428 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056428 B. Wing 03/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

California Nursing & Rehabilitation Center 2299 North Indian Canyon Drive Palm Springs, CA 92262

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 0801 During an interview on 3/03/25 at 3:29 PM with the DSM-RD, the DSM-RD stated it was important for the facility to follow the approved menus to ensure residents receive the appropriate therapeutic diet. Level of Harm - Minimal harm or potential for actual harm According to M. [NAME] et al., Journal of Renal Nutrition, Vol 26, No 4 (July), 2016: pp e19-e22, .Brown rice: can be included in a renal diet . with careful consideration of overall daily intake of phosphorus and Residents Affected - Many potassium .

Review of the undated facility P&P titled Menus indicated To ensure that the Facility provides meals to residents that meet the requirements of the Food and Nutrition Board .Daily menus will include planning for three meals and an evening snack .

3. During the facility's recertification survey from 2/24/25 - 3/3/25 multiple observations, interviews and record reviews were conducted in the kitchen regarding unsafe and unsanitary food practices pertaining to a) unclean ice machines, high freezer temperatures, b) high chlorine dish machine sanitizer levels, and c) unclean dishes stored with clean dishes.

a) On February 24, 2025, at 10:38 a.m., a joint observation and interview was conducted at the facility's ice machine. The ice machine had dark brown and black debris inside the bin, on and inside the ice cubes. There was a light brown pinkish colored slimy substance inside the internal rubber and metal ice making parts, as well as the external metal pan. The Maintenance Supervisor (MS) was in the process of removing parts of the outer and inner components of the machine. The MS stated he was cleaning the ice machine with green Palmolive dish soap and an aqua colored solution inside a clear plastic cleaning bottle. The MS stated he cleaned inside the ice machine bin and internal ice making parts, once a month.

On February 24, 2025, at 10:45 a.m., a concurrent observation and interview with the Director of Nursing (DON), and the DSM-RD was conducted. The DON and the DSM-RD acknowledged the dirty brown, black and pinkish slime build-up and debris in the ice machine. The DSM-RD stated the condition of the ice machine was not acceptable because residents with weakened immune systems could get sick, be hospitalized , and even death if they consume the ice.

b) During the initial kitchen tour on February 24, 2025, at 9:15 a.m., a concurrent observation and interview with [NAME] (CK) 1 was conducted at the reach in freezer. The freezer was full of bags of mixed vegetables

on the middle shelf, cases of chicken and beef at the bottom shelf and large tubs of ice cream along with pre-cooked bread rolls. The ice cream was very soft, and tub was bendable. The temperature internal temperature of the freezer was 54 degrees Fahrenheit (F). A surveyor placed their digital thermometer inside

the reach in freezer and the temperature was 49.8 degrees F. CK 1 acknowledged the refrigerator's internal temperature and stated, it should be 32 degrees.

On 2/25/25 at 12:01 PM, an observation of the reach-in freezer internal thermometer indicated the temperature was 43 degrees F and the Surveyor's thermometer was 41.9 degrees F.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 67 056428 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056428 B. Wing 03/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

California Nursing & Rehabilitation Center 2299 North Indian Canyon Drive Palm Springs, CA 92262

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 0801 On February 24, 2025, at 4:54 p.m., an observation and interview were conducted with the Dietary Services Manager-Registered Dietitian (DSM-RD) in the kitchen. The reach-in freezer thermometer read 55 degrees Level of Harm - Minimal harm or F. There was water condensation collection on the ceiling. The DSM-RD acknowledged the 55 degrees F potential for actual harm and stated the reach-in freezer temperatures sometimes runs higher than normal, especially when the kitchen staff go in and out of it. The DSM-RD further stated the temperature should not be higher than 5 or 6 Residents Affected - Many degrees above zero degrees to keep foods frozen. The DSM-RD also stated the internal thermometer may need to be changed.

On February 25, 2025, at 9:08 a.m., a concurrent observation and interview was conducted in the kitchen.

The temperature on the internal thermometer inside the reach in freezer was 16 degrees F. The DSM-RD further stated the temperature was 0 degrees or negative degrees F in the morning at 6:00 a.m. The DSM-RD also stated they may look into replacing the freezer in the future.

c) On February 24, 2025, at 9:55 a.m., a concurrent observation and interview was conducted with the DSM-RD in the kitchen. The DSM-RD acknowledged there were three 3 large metal pans had water and food debris on them. The pans were dripping wet and stacked on top of each other. Four pie pans with water and debris on them, two (2) strainers with white dried residue and 2 skillets with dried particles on them were stored under a counter. There were four rubber cutting boards with multiple indented markings were found under the food prep counter. The DSM-RD stated the strainers were not clean and verified the dry white substance should not be there. The DSM-RD further stated the wet dishes should be dried before they were put away and not stored wet.

During an interview with the Administrator (ADM) on 2/27/25 at 5:00 PM, the ADM stated the facility recently hired the DSM-RD to be the full-time RD. However, the ADM further stated the Registered Dietitian duties should still be completed appropriately to protect the health and safety of the residents, according to the RD contractual agreement.

During an interview on 3/03/25 at 3:29 PM with the DSM-RD, the DSM-RD stated it was important for the kitchen and food service operations function under safe and sanitary conditions to protect the residents.

According to the 2022 Federal Food Code, section 3-307.00 Miscellaneous Sources of Contamination, indicated, .Food shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306.

A review of the facility's policy and procedures titled, Dietary Department -Infection Control dated June 4, 2024, indicated, .Personal cleanliness is required in sanitary food preparation .cover hair, beard, and mustache with an effective hair restraint, such as hats, hair coverings, or nets while in any kitchen and food storage areas.

During a review of the facility's monthly Kitchen Sanitation & Food Safety Inspection reports dated 8/30/24 to 1/25/25 completed by the RD, indicated the following concerns .Let silverware completely dry before putting away .Food debris observed in food bins .Coffee machine needs a deep cleaning .Cold Storage .44 .Freezer . Frost Observed and 0 degrees F or below .Partially Met .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 67 056428 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056428 B. Wing 03/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

California Nursing & Rehabilitation Center 2299 North Indian Canyon Drive Palm Springs, CA 92262

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 0801 Review of the facility's job description titled Registered Dietitian dated 10/10/23, indicated .Summary: Provide Medical Nutrition Therapy and work with the Dietary Supervisor to ensure that quality food service Level of Harm - Minimal harm or and nutritional care are being provided to residents by performing the following duties. Essential Duties and potential for actual harm Responsibilities: Evaluates the Medical Nutrition Therapy needs of the residents and implements appropriate interventions to improve their nutritional status .Coordinates with the Nutrition Services Supervisor/Manager Residents Affected - Many the review and customization of the regular and therapeutic menus .Routinely inspects the food service areas and practices for compliance with company policies, procedures, and standards with applicable federal, state, and local regulations .

Review of the facility's Registered Dietitian Services Contractor Agreement contract dated 1/27/22, indicated . 1. Services .d. Assess all residents at the .facility on an annual basis and quarterly for residents .in regard to nutritional parameters such as weight variance .abnormal labs .e. Review Quarterly Assessments .for nutrition concern triggers - significant weight loss .abnormal labs .g. Complete Recommendations for Nutrition Interventional based on nutritional assessment to meet the estimated nutrition needs of the resident .j. Approve the .Menu System .k. Review and approve the Diet Manual on an annual basis .q. Conduct kitchen inspections for safety and sanitation .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 67 056428 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056428 B. Wing 03/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

California Nursing & Rehabilitation Center 2299 North Indian Canyon Drive Palm Springs, CA 92262

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 0802 Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Level of Harm - Minimal harm or potential for actual harm 49113

Residents Affected - Some Based on observation, interview, and record review, the facility did not ensure the kitchen staff in the food and nutrition services department were trained according to standards of practice for food safety, sanitation, and facility policy when:

1. A [NAME] did not know how to use the chlorine test strips to test the sanitizer in the dish machine.

2. A Dietary Aide did not know how to calibrate a food thermometer.

These failures in staff competency resulted in exposing 72 residents who consume food from the kitchen to practices associated with food borne illness as well as bacterial and chemical cross contamination and had

the potential to cause illness.

Findings:

1. On February 24, 2025, at 10:32 a.m., [NAME] (CK) 2 demonstrated how to test the sanitizer in the dish machine and described how it operated. CK 2 dipped a test strip from the container and compared the color shades of lavender to purple. CK 2 stated it was dark purple which was 300 ppm to 400 ppm (parts per million, a measure of units), and it should be 100 ppm to 200 ppm, according to the test strip container.

On February 24, 2024, at 4:10 p.m., an observation and interview were conducted with Dietary Aide (DA) 1. DA 1 dipped the test strip in the water in the dish machine basin. DA 1 stated it was okay to dip the test strip into the water residue. DA 1 compared the color shades to the lavender to purple colors on the test strip container, and stated the test strip was purple which indicated 100-200 ppm (parts per million-a unit of measurement). DA 1 stated the color was okay, and further stated he did not know the correct level should be 50-100 ppm.

During an interview on February 24, 2025, at 4:21 p.m., with the Dietary Service Manager-Registered Dietitian (DSM-RD), the DSM-RD acknowledged CK 2 and DA 1 did not know how to correctly test the sanitizer in the low temperature dish machine and the concentration should be 50 ppm to 100 ppm. The DSM-RD further stated they should know how to correctly test the sanitizer and may need an in-service.

According to the 2022 Federal Food Code, section 4-302.14, titled Sanitizing Solutions, Testing Devices, indicated, .Testing devices to measure the concentration of sanitizing solutions are required for 2 reasons: .

the use of chemical sanitizers requires minimum concentrations of the sanitizer . to ensure sanitization, and 2, too much sanitizer in the final rinse water could be toxic .

A review of the facility's policy and procedure titled, Dish Machine Operation and Cleaning dated October 1, 2014, indicated, .Routinely monitor soap, sanitizer and rise agent to ensure adequate supply throughout operation of the dish machine .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 67 056428 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056428 B. Wing 03/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

California Nursing & Rehabilitation Center 2299 North Indian Canyon Drive Palm Springs, CA 92262

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 0802 2. On February 25, 2025, at 10:13 a.m. an observation and interview with Dietary Aide (DA) 2 and the DSM-RD, was conducted in the kitchen. DA 2 took the thermometer wiped it with an alcohol wipe, then Level of Harm - Minimal harm or stated she was not sure how to calibrate the thermometers because the cook calibrated the thermometers. potential for actual harm DA 2 further stated it was important to know how to properly calibrate thermometers so food would be at a safe temperature for the residents to eat. The DSM-RD acknowledged DA 2 did not know how to calibrate Residents Affected - Some the thermometer.

According to the 2022 Federal Food Code, section 4-302.12, titled Food Temperature Measuring Devices.

The presence and accessibility of food temperature measuring devices is critical to the effective monitoring of food temperatures. Proper use of such devices provides the operator or person in charge with important information with which to determine of temperatures should be adjusted or if foods should be discarded.

A review of the facility's [NAME] Job Description, undated, indicated, .Technical .Basic understanding of cleanliness, organization, and safety .Qualifications .Performs job duties in a safe and sanitary manner .

A review of the facility's Dietary Assistant/Dishwasher Job Description, undated, indicated, .Technical . Maintains a safe and sanitary work environment .Qualifications .Basic understanding of sanitation, organization, and safety .

A review of the facility's policy and procedure titled, Calibrating a Thermometer dated July 1, 2014, indicated, .The purpose is to provide the dietary department with guidance for calibrating bi-metallic food thermometers . Food thermometers will be calibrated periodically to ensure proper food temperatures.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 67 056428 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056428 B. Wing 03/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

California Nursing & Rehabilitation Center 2299 North Indian Canyon Drive Palm Springs, CA 92262

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 0803 Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38924

Residents Affected - Few Based on observation, interview and record review, the facility failed to ensure the therapeutic menu was followed for two residents, a sampled resident 66, and unsampled resident 17, on renal diets (a diet to protect the health of the kidneys).

These failures led to the two residents receiving foods that did not meet their nutritional needs and may have further compromised their health status. The facility census was 72.

Findings:

Review of Resident 17's Admission Record dated 2/28/25 indicated Resident 17 was admitted on [DATE REDACTED] and readmitted on [DATE REDACTED] to the facility with diagnoses that included COPD (chronic obstructive pulmonary disease- difficulty breathing due to obstruction in the lungs), CKD (chronic kidney disease- inability of the kidneys to effectively filter wastes) and HLD (hyperlipidemia- high levels of fat in the blood).

Review of Resident 17's minimum data set (MDS- standardized assessment tool used to assess and monitor resident health status, functional capabilities, and needs) Brief Interview Mental Status (BIMS) dated 2/28/25 indicated a score of 11.

Review of Resident 66's Admission Record dated 2/28/25 indicated Resident 66 was admitted on [DATE REDACTED] to

the facility with diagnoses that included dependence on renal dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly), acute kidney failure (inability of the kidneys to effectively filter wastes), type 2 diabetes (high levels of sugar circulating in the blood), hypertension (high blood pressure), and hyperlipidemia.

Review of Resident 66's minimum data set (MDS) BIMS dated 2/28/25 indicated a score of 11.

A review of the facility's Compact Roster by Name Report, dated 2/25/25 indicated Resident 66's diet was . Diet . Renal, CCHO (consistent carbohydrates), Fluid Restriction 1500 mL (milliliters) per day, Lactose (milk sugar) Free .80 gram and indicated Resident 17's diet was .Renal 60 gram-Regular-Large .

A review of the facility's Cook's Spreadsheet Winter Menus- (Pg 2) .Week 1 .Tuesday .2/25/25, indicated . Renal Diets .Herb Crusted Beef Gravy 2 oz. meat, [NAME] with margarine #12 (1/3 cup), Zucchini with margarine 1/2 cup .Garlic Bread 1 slice .

During an observation and interview on 2/25/25 at 11:59 A.M. of the lunch meal trayline service, [NAME] (CK 1) stated a renal diet meal tray would be get .herb crusted chicken, white rice, and zucchini . CK 1 stated

they didn't have brown rice to serve and white rice is the same as brown rice.

During an observation and interview on 2/25/25 at 12:30 P.M. in Resident 17's room, the resident was eating his lunch meal. Resident 17 ate the white rice and herb chicken and stated the food was okay, but it didn't have any flavor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 67 056428 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056428 B. Wing 03/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

California Nursing & Rehabilitation Center 2299 North Indian Canyon Drive Palm Springs, CA 92262

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 0803 On 2/26/25 at 2:46 P.M., an interview was conducted with the Dietary Services Manager-Registered Dietitian (DSM-RD). The DSM-RD stated it is her expectation that the Cooks and kitchen staff follow the printed Level of Harm - Minimal harm or menus, so the resident receives the appropriate diet and nutrition to meet their needs. potential for actual harm

During an interview on 3/03/25 at 3:29 PM with the DSM-RD, the DSM-RD stated it was important for the Residents Affected - Few facility to follow the approved menus to ensure residents receive the appropriate therapeutic diet.

According to M. [NAME] et al., Journal of Renal Nutrition, Vol 26, No 4 (July), 2016: pp e19-e22, .Brown rice: can be included in a renal diet . with careful consideration of overall daily intake of phosphorus and potassium .

Review of facility document titled Renal Diet 40-60-80 Gram Protein, Low Potassium, Low Salt Menu dated 2020, indicated .This diet is used for the resident with renal insufficiency or for residents with renal failure not

on dialysis. This diet regulates the dietary intake of sodium, potassium and protein to lighten the work of the diseased kidney .

Review of the undated facility P&P titled Menus indicated .To ensure that the Facility provides meals to residents that meet the requirements of the Food and Nutrition Board .Daily menus will include planning for three meals and an evening snack .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 67 056428 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056428 B. Wing 03/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

California Nursing & Rehabilitation Center 2299 North Indian Canyon Drive Palm Springs, CA 92262

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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or 49113 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the food was served at an Residents Affected - Some acceptable temperature and palatability taste to the residents, according to the facility policy.

This failure had the potential to affect meal and food intake which could impair the nutrition status of the 74 residents who consumed food from the kitchen.

Cross Reference

F-F908), and timely identification and repair of broken call light bell system (see findings under

F-F919).

On March 3, 2025, at 2:40 p.m., an interview and a concurrent record review with the Administrator (ADM) was conducted to discuss the facility's QAPI program. The ADM stated the QAPI committee consists of the ADM, Director of Nursing (DON), Medical Director, Radiology, Pharmacy, Laboratory, and the heads of the facility departments. The ADM stated the facility did not have a QAPI program which identified, corrected, and improved the issues related to the identified broken call light, kitchen and nutrition services. The QAPI program did identify issues with the weight loss but did not evaluate the interventions put in place for weight loss put in place prior to December 2024.

A review of the facility document titled, Quality Assurance and Performance Improvement (QAPI) Program, dated March 20, 2024, and effective June 4, 2024, indicated, . the facility evaluates the effectiveness of its QAPI program at least annually and as needed, and presents their conclusions to the Governing Body for

review .The QAPI Committee, Administrator, and the Governing Body shall review a summary ofproblems(sic) and corrective measures .Each department or service reviews its approaches to monitoring performance and outcomes andproviodes(sic) a summary of its findings to the QAPI committee annually and as needed .The QAPI committee evaluates these various reports to help define issues, plan and implementactions(sic), and ensure monitoring and follow-up .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 67 056428 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056428 B. Wing 03/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

California Nursing & Rehabilitation Center 2299 North Indian Canyon Drive Palm Springs, CA 92262

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 39920 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure infection control practices Residents Affected - Some were implemented when:

1. The laundry room door was closed and staff were observed passing through the clean area of the laundry from the hallway;

2. Nursing staff failed to properly clean and disinfect shared blood pressure (BP-pressure of blood in blood vessels) cuffs and stethoscopes for Residents 475 and 58, according to the disposable Sani-Cloth disposable wipe manufacturer's specified contact time (the time the resident equipment was to be in contact with the disposable wipes to kill micro-organisms). In addition, the facility failed to properly clean and disinfect the shared stethoscope after use according to facility's policy; and

3. The lunch meal trays for Residents 17 and 23 were placed in the residents' room next to unsanitary bodily equipment.

These failures had exposed vulnerable residents to potentially hazardous substances due to cross-contamination, which could increase development of infections.

Findings:

1. On February 27, 2025, at 8:53 a.m., a concurrent observation and interview was conducted with the Laundry Assistant (LA). The laundry door was observed open from the resident rooms' hallway, and staff were observed going in and out of the service entrance door (the exit door to the patio outside - service entrance). The LA was observed from the doorway, folding linens on the table. The LA stated she was folding clean linens. A Certified Nursing Assistant (CNA) was observed to have entered the clean area, because the laundry door was open from the hallway, and had a conversation with the LA.

On February 27, 2025, at 9:35 a.m., a concurrent observation and interview was conducted with the LA. The LA was asked where the clean area of the laundry room was, and the LA pointed at the opposite end of the room, where the linen folding table for clean linen was, and the door was observed open to the resident rooms' hallway. The area where the LA pointed as the clean area did not have a sign posted as clean area.

On February 27, 2025, at 9:55 a.m., a concurrent observation and interview was conducted with the Housekeeping Supervisor (HS). The HS stated the laundry room door leading to the resident rooms' hallway was always open.

On March 3, 2025, at 2:43 p.m., an interview was conducted with the HS. The HS stated the door laundry door should stay closed, and when the door was open, the staff went through the clean area of the laundry, increasing the risk of contamination.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 67 056428 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056428 B. Wing 03/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

California Nursing & Rehabilitation Center 2299 North Indian Canyon Drive Palm Springs, CA 92262

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 0880 On March 3, 2025, at 2:52 p.m., an interview was conducted with the Infection Preventionist (IP). The IP stated when the laundry door was open, facility staff going through the clean area of the laundry was an Level of Harm - Minimal harm or infection control issue. potential for actual harm

The facility policy and procedure titled, Laundry-Route & Process, dated January 1, 2012, was reviewed. The Residents Affected - Some policy indicated, .Purpose .To ensure that the Facility provides a sufficient supply of clean linens for all residents .Laundry Route and Process: On-site Laundry .A clean and safe environment is always maintained .

46393

2. During a medication pass observation on February 25, 2025, at 9:11 a.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 was observed using a shared manual BP cuff and stethoscope to measure Resident 475's BP. LVN 4 was observed wiping the shared manual BP cuff with a Sani-Cloth disposable wipe and did not disinfect the manual BP cuff according to the manufacturer specified contact time. Additionally, LVN 4 was observed wiping the shared stethoscope with an alcohol pad.

During another medication pass observation on February 25, 2025, at 10:04 a.m. with LVN 3, LVN 3 was observed using a shared manual BP cuff and stethoscope to measure Resident 58's BP. LVN 3 was observed wiping the shared manual BP cuff with a Sani-Cloth disposable wipe and did not disinfect the manual BP cuff and stethoscope according to the manufacturer specified contact time.

During an interview on February 25, 2025, at 11:37 a.m. with the Infection Prevention (IP) nurse, the IP stated nursing staff were expected to clean and disinfect all shared resident care equipment after use with Sani-Cloth disposable wipes and stated the contact time was two (2) minutes. The IP stated contact time meant nurses were expected to saturate the shared equipment with the wipe, then let the equipment dry for two (2) minutes. The IP sated nurses were not instructed to keep the equipment wet for two (2) minutes. Additionally, the IP stated alcohol pads should not have been used to disinfect any resident care equipment.

During the same interview, the IP reviewed the manufacturer's labeled instructions on the Sani-Cloth disposable wipe bottle and acknowledged nursing staff should have been instructed to keep equipment wet for two (2) minutes to achieve contact time when they wiped shared resident care equipment according to

the manufacturer's instructions.

During an interview on February 26, 2025, at 5:19 p.m. with the Director of Nursing (DON), the DON stated nursing staff were expected to follow the Sani-Cloth manufacturer's instructions for contact time to achieve proper kill time of organisms. Additionally, the DON stated nursing staff should not have used alcohol pads for cleaning or disinfecting shared resident care equipment because alcohol pads were not effective for killing organisms. The DON stated it was important to follow infection control procedures to prevent the spread of infections.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 67 056428 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056428 B. Wing 03/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

California Nursing & Rehabilitation Center 2299 North Indian Canyon Drive Palm Springs, CA 92262

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 0880 During a review of the facility's policy and procedure (P&P) titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated January 1, 2012, the P&P indicated, Resident-care equipment, including Level of Harm - Minimal harm or reusable items and durable medical equipment will be cleaned and disinfected according to the current CDC potential for actual harm (Centers for Disease Control and Prevention- a nationally recognized disease control and prevention organization) recommendations for disinfection .Non-critical items are those that come in contact with intact Residents Affected - Some skin but not mucous membrane .Reusable items are cleaned and disinfected or sterilized between residents. (e.g., stethoscopes, durable medical equipment) .Reusable resident care equipment is decontaminated and/or sterilized between residents according to manufacturers' instructions.

During a review of the manufacturer's instructions for contact time for the Sani-Wipes provided by the facility,

the manufacturer's instructions indicated, Contact time .thoroughly wet surface. Allow surface to remain wet for two (2) minutes. Let air dry.

49113

3. A. On February 25, 2025, at 5:49 p.m., Resident 17's evening meal tray was observed on his bedside table next to his urinal (a container used to collect urine and is made for either male).

On February 25, 2025, at 5:54 p.m., a concurrent observation and interview with CNA 5 was conducted. CNA 5 acknowledge Resident's 17 meal tray was placed on top of his bedside table next to his urinal. CNA 5 further stated, That should not be there, it is not sanitary, let me remove the urinal from the bedside table.

B. On February 25, 2025, at 5:58 p.m., a concurrent observation and interview was conducted with Certified Nurse Assistant (CNA) 6. Resident 23's meal tray was observed placed on a visitor's chair. The CNA stated

the meal tray should not be placed on a chair and stated there was no bedside table in the room. The CNA acknowledged placing the tray on the chair was not sanitary.

On March 3, 2025, at 2:59 p.m., an interview with the Dietary Service Manager/ Registered Dietitian/ (DSM-RD) was conducted. The DSM-RD stated she expects the meals and food to be served to the residents in a sanitary manner to control and prevent infections.

According to the 2022 Federal Food Code, section 3-307.11, titled Miscellaneous Sources of Contamination. Indicated, Food shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306.

A review of the facility's policy and procedures titled, Food Temperatures, dated 10/10/2023, indicated, .Food items will be handled in accordance with recommended sanitary practice .to prevent foodborne illnesses.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 67 056428 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056428 B. Wing 03/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

California Nursing & Rehabilitation Center 2299 North Indian Canyon Drive Palm Springs, CA 92262

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 0908 Keep all essential equipment working safely.

Level of Harm - Minimal harm or 38924 potential for actual harm 49113 Residents Affected - Many Based on observation, interview, and record review, the facility failed to ensure essential food and nutrition services equipment, such as the reach in freezer, and ice machine were maintained in safe operating condition.

These failures had the potential to impact the ability of dietary staff to prepare, store, and serve food in a safe and sanitary manner. Resident census was 72 at time of survey.

Findings:

1. During the initial kitchen tour on February 24, 2025, at 9:15 a.m., a concurrent observation and interview with [NAME] (CK) 1 was conducted at the reach in freezer. The freezer was full of bags of mixed vegetables

on the middle shelf, cases of chicken and beef at the bottom shelf and large tubs of ice cream along with pre-cooked bread rolls. The ice cream was very soft, and tub was bendable. The temperature internal temperature of the freezer was 54 degrees Fahrenheit (F). A surveyor placed their digital thermometer inside

the reach in freezer and the temperature was 49.8 degrees F. CK 1 acknowledged the refrigerator's internal temperature and stated, it should be 32 degrees.

On 2/25/25 at 12:01 PM, an observation of the reach-in freezer internal thermometer indicated the temperature was 43 degrees F and the Surveyor's thermometer was 41.9 degrees F.

On February 24, 2025, at 4:54 p.m., an observation and interview were conducted with the Dietary Services Manager-Registered Dietitian (DSM-RD) in the kitchen. The reach-in freezer thermometer read 55 degrees F. There was water condensation collection on the ceiling. The DSM-RD acknowledged the 55 degrees F and stated the reach-in freezer temperatures sometimes runs higher than normal, especially when the kitchen staff go in and out of it. The DSM-RD further stated the temperature should not be higher than 5 or 6 degrees above zero degrees to keep foods frozen. The DSM-RD also stated the internal thermometer may need to be changed.

On February 25, 2025, at 9:08 a.m., a concurrent observation and interview was conducted in the kitchen.

The temperature on the internal thermometer inside the reach in freezer was 16 degrees F. The DSM-RD further stated the temperature was 0 degrees or negative degrees F in the morning at 6:00 a.m. The DSM-RD also stated they may look into replacing the freezer in the future.

During an interview with the Administrator (ADM) and Maintenance Supervisor (MS) on 2/25/25 at 9:33 AM

in the kitchen. The ADM stated the freezer temperature should be able to freeze foods at the correct temperature to keep foods frozen. The MS stated he would have to contact a technician and get a small freezer unit, if needed.

During a kitchen observation of the reach-in freezer on 2/25/25 at 3:23 PM, the internal thermometer read 10 degrees F and the Surveyor's thermometer was 15 degrees F.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 67 056428 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056428 B. Wing 03/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

California Nursing & Rehabilitation Center 2299 North Indian Canyon Drive Palm Springs, CA 92262

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 0908 A review of the facility's reach-in freezer temperature log dated 2/24/25 and 2/25/25 indicated the temperature was '0' degrees and -12 degrees signed by CK 1. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's monthly Kitchen Sanitation & Food Safety Inspection reports dated 8/30/24 to 1/25/25, completed by the RD, indicated .Cold Storage .44 .Freezer .Frost Observed, 0 degrees F or below . Residents Affected - Many Partially Met .

According to the 2022 Federal Food Code, section 3-302.11 titled Packaged and Unpackaged Food - Protection Separation, Packaging, and Segregation, .The freezer equipment should be designed and maintained to keep foods in the frozen state. Corrective action should be taken if the storage or display unit loses power or otherwise fails .

According to the 2022 Federal Food Code, section 4-501.00, titled Good Repair and Proper Adjustment. (Equipment) Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk .

2. On February 24, 2025, at 10:38 a.m., a joint observation and interview was conducted at the facility's ice machine. The Maintenance Supervisor (MS) was removing parts of the outer and inner components of the machine. The ice machine had an Out of Service sign on it. The ice machine had dark brown and black debris inside the bin, on and inside the ice cubes. There was a light brown pinkish colored slimy substance inside the internal rubber and metal ice making parts, as well as the external metal pan. The MS had green Palmolive dish soap and an aqua colored solution inside a plastic cleaning bottle. The MS stated he used both to clean products to clean inside the bin, internal ice making parts, filters, and the outside of the ice machine.

On February 24, 2025, at 10:45 a.m., a concurrent observation and interview with the Director of Nursing (DON), and the DSM-RD was conducted. The DON and the DSM-RD observed the brown and black debris, brown pinkish colored slime inside the internal metal cover and rubber grid touching water component parts.

The DSM-RD stated the condition of the ice machine was not acceptable. The DSM-RD also stated residents with weaken immune systems, could get sick, be hospitalized , and even death if they consume. The DON further stated, this was not acceptable, and residents could get sick. The DON also stated we will get this fixed. The DSM-RD and DON further stated the facility will need to get bags of ice from the store to provide ice to the residents until the ice machine is cleaned correctly.

On February 25, 2025, at 8:45 a.m., an observation and interview were conducted with the ADM (Administrator) and MS. The ice machine still had a sign Out of Service on it. The ADM and MS stated the ice machine was not in service because they were waiting for a service technician to clean the machine and replace parts. The ADM stated it was important to have a thoroughly clean and sanitized ice machine so residents do not receive ice that could make them sick.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 67 056428 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056428 B. Wing 03/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

California Nursing & Rehabilitation Center 2299 North Indian Canyon Drive Palm Springs, CA 92262

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 0908 According to the HOSHIZAKI (Ice Machine Manufacturer), service manual dated 2/21/2019, and revised 7/19/2023, indicated .Wipe down BC (Bin Control-sensor that monitors the ice level in the storage bin) with a Level of Harm - Minimal harm or mixture of 1 part Hoshizaki Scale Away and 25 parts warm water .Rinse the parts thoroughly with clean potential for actual harm water .Float Switch Cleaning .scale may build up on float switch (FS-small device that monitors the water level in the ice machine's reservoir) .scale may cause FS to stick .wipe down FS assembly's housing, shaft, Residents Affected - Many float, and retainer rod with a mixture of 1 part Hoshizaki Scale Away and 25 parts water .clean the inside of

the rubber boot and hose with cleaning solution .rinse parts thoroughly with clean water .

According to the 2022 Federal Food Code section 3-303.11, titled Ice Used as Exterior Coolant, Prohibited as Ingredient. Ice that has been in contact with unsanitized surfaces .may contain pathogens and other contaminants .if this ice is then used as a food ingredient, it could be contaminated .

According to the 2022 Federal Food Code section 4-204.17, titled Ice Units, Separation of Drains. Liquid waste drain lines passing through ice machines and storage bins present a risk of contamination due to potential leakage of the waste lines and the possibility that contaminants will gain access to the ice through condensate migrating along the exterior of the lines. Liquid drain lines passing through the ice bin are, themselves, difficult to clean and create other areas that are difficult to clean where they enter the unit . The potential for mold and algal growth in this area is very likely due to the high moisture environment. Molds and algae that form on the drain lines are difficult to remove and present a risk of contamination to the ice stored

in the bin.

A review of the facility's policy and procedure titled, Ice Machine - Operation and Cleaning, dated October 1, 2014, indicated, .The dietary staff will operate the ice machine according to the manufacturer's guidelines,

the ice machine will be cleaned regularly .On no less than a monthly basis, remove the ice to wash the inside of the machine .Maintenance staff will clean the ice making mechanism according to manufacturer's guidelines .

A review of the facility's policy and procedure titled, Maintenance Service, dated January 1, 2012, indicated, .

The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times .Providing routinely scheduled maintenance serve to all areas .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 67 056428 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056428 B. Wing 03/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

California Nursing & Rehabilitation Center 2299 North Indian Canyon Drive Palm Springs, CA 92262

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 0912 Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Level of Harm - Potential for minimal harm 51080

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure that bedrooms measured at least 80 square feet per resident, in bedrooms occupied by multiple residents (Rooms 3, 17, 20, and 33).

Findings:

On February 24, 2025, at 9:21 a.m., the facility Administrator stated the rooms that had four residents per room did not meet the required 80 square feet per resident. This included the following rooms: 3, 17, 20, and 33.

Rooms 3, 17, 20, and 33 housed four residents in each room and did not measure at least 80 square feet per resident, as required. All four rooms were measured as 310 square feet.

During all days of the survey, no negative impact was observed to the health and safety of the residents. Residents residing in the rooms, who were interviewable, stated they were comfortable in the space provided.

The survey team recommends the room variance continue provided that a yearly waiver is requested, and

the health and safety of the residents is not adversely affected.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 67 056428 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056428 B. Wing 03/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

California Nursing & Rehabilitation Center 2299 North Indian Canyon Drive Palm Springs, CA 92262

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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44173 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the call light system (a Residents Affected - Many communication system that allow the residents to call for staff assistance) was fully functional when:

1. The call light system panel did not have an audible sound; and

2. Resident 23 did not have a call light button installed, available, and within reach.

These failures had the potential for Resident 23 and the residents in the facility not to receive assistance from the staff in a timely manner.

Findings:

1. On February 26, 2025, at 9:45 a.m., the call light panel located on the wall of the nurse's station was observed with the light on for room [ROOM NUMBER]. The call light panel did not have an audible sound while the light was on in room [ROOM NUMBER].

On February 26, 2025, at 9:51 a.m., during a concurrent interview and record review with the Registered Nurse Supervisor (RNS), the RNS stated there should be an audible sound heard from the call light panel when a light is on. The RNS stated the maintenance department was aware the call light panel did not have

an audible sound when a light is on. The equipment log located at the nurse's station for February 2025 did not indicate the call light panel was reported for repair. The RNS stated the maintenance department should have the copy for January 2025.

On February 26, 2025, at 10:03 a.m., during an interview with the Director of Nursing (DON) he stated he was not sure if there should be an audible sound from the call light panel when a light is on. He stated he will have to check with the Maintenance Supervisor (MS) if he was aware the call light system was not fully functional.

During an interview on February 26, 2025, at 10:11 a.m., with the MS, he stated he was aware the call light panel was not fully functional since January 3, 2025. He stated the call light panel did not have an audible sound when a light is on. He stated he received an estimate from an outside company to fix or replace the call light system and the previous administrator received a copy of the estimate.

On February 26, 2025, at 10:45 a.m., during an interview with Licensed Vocational Nurse (LVN) 4, he stated

he was not aware there should be an audible sound from the call light panel at the nurse's station when the call light was turned on from the resident's room. LVN 4 stated he was only alerted a call light button was turned on from the resident's room when he checked the call light panel.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of 67 056428 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056428 B. Wing 03/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

California Nursing & Rehabilitation Center 2299 North Indian Canyon Drive Palm Springs, CA 92262

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 0919 On February 26, 2025, at 11 a.m., during an interview with the administrator (ADM) and the DON, the ADM and the DON stated they were not aware the call light button, when turned on from the resident's room, did Level of Harm - Minimal harm or not have an audible sound at the nurse's station. The ADM stated the QAPI (Quality Assurance and potential for actual harm Performance Improvement - a data driven approach to improving quality of care and services) meeting conducted in January 2025, did not indicate the facility's call light system was not fully functional. During the Residents Affected - Many interview with the ADM and the DON, the call light panel at the nurse's station turned on for room [ROOM NUMBER]. The call light panel did not have an audible sound while the light was on.

The facility document titled, Communication - Call System, revised January 1, 2012, indicated, .The facility will provide a call system to enable residents to alert the nursing staff from their rooms and toileting/bathing facilities .

The facility document titled, Maintenance Service, revised October 1, 2024, indicated, .The Maintenance Department maintains all areas of the building, grounds, and equipment .The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times .

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2. On February 24, 2025, at 10:48 a.m., an observation with concurrent interview was conducted with Resident 23. Resident 23 was observed, laying in bed, alert, confused, and yelling. Resident 23 stated he did not know how to use the call light and he needed to be changed. Observed no call light within reach of Resident 23. Observed no call light cord coming from the wall to Resident 23's bed.

On February 24, at 10:56 a.m., a interview was conducted with CNA 2. CNA 2 stated Resident 23 constantly yells for help; yelling is how he communicates his need for help and has never used the call light. CNA 2 stated she could not locate Resident 23's call light within the bed or coming from the wall. CNA 2 further stated she makes rounds and checks for call lights each morning at the start of her shift. CNA 2 stated the facility policy is call lights should be within the resident's reach.

On February 24, 2025, Resident 23's record was reviewed. Resident 23 was admitted to the facility on [DATE REDACTED], with diagnosis that included psychosis (a mental health condition characterized by a loss of contact with reality), altered mental status (change in a person's level of consciousness, awareness, and cognitive functions), disorder of the brain (conditions that impact the brain's normal functioning), diabetes mellitus (chronic condition characterized by high blood sugar levels).

The Quarterly Minimum Data Set (MDS-an assessment tool) dated January 8, 2025, indicated a BIMS score (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident, a score from 0 to 15 that measures a person's cognitive functioning) of 6 (6- severe cognitive impairment). The MDS further indicated Resident 23 was occasionally incontinent of bowel and frequently incontinent of bladder.

On February 27, 2025, at 10:11 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated the expectations for call lights are the call lights should always be accessible and in reach for every resident. The DON further stated the facility process was not followed because all residents should have a call light available at all times whether they know how to operate the call light or not.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of 67 056428 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056428 B. Wing 03/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

California Nursing & Rehabilitation Center 2299 North Indian Canyon Drive Palm Springs, CA 92262

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 0919 The facility policy and procedure titled Communication-Call System dated January 1, 2012, indicated, .The facility will provide a call system to enable residents to alert the nursing staff from their rooms .call cords will Level of Harm - Minimal harm or be placed within the resident's reach in the resident's room .if call bell is defective, it will be reported potential for actual harm immediately to maintance and replaced immediately .

Residents Affected - Many

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of 67 056428