Palm Springs Healthcare & Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain proper use of Low Air Low (LAL) Mattresses (A specialized air-filled mattress used to treat and prevent the development of pressure ulcers - skin damage caused by prolonged pressure to one area of the body), when the resident's LAL pump/air pressure was not maintained at the proper setting for four of 6 residents reviewed (Residents 1, 2, 3 and 4). This failure had the potential to contribute to the development and/or prolonged healing of pressure ulcer's (PUs).

Inspectors wroteBased on interview and record review, the facility failed to notify the resident's representative, for one of three residents reviewed (Resident 5), when Resident 5 experienced a fall. This failure resulted in the resident's representative not being aware of the resident's change of condition.

Inspectors wroteBased on interview and record review the facility failed to ensure a safe environment when: 1. Use of siderails were not implemented in accordance with the siderail evaluation conducted on May 24, 2025, for Resident 2. 2. A physician order was not obtained to implement siderails for one of three sampled residents (Resident 1). These failures had the potential to result in accidents or injury while in bed for Residents 1 and 2.

Inspectors wroteBased on interview and record review, the facility failed to maintain an accurate reconciliation of the controlled medication that had been administered for two of three sampled residents (Residents 2 and 3). This failure increased the risk for medication error, which could negatively impact the residents' health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement proper infection control precaution in accordance with the facility policy and procedure, when one of nine residents (Resident 1) was identified positive of carbapenem-resistant pseudomonas aeruginosa (CRPA - a type of bacteria resistant to a powerful class of antibiotics) on March 28, 2025. This failure had the potential to negatively impact the vulnerable residents in the subacute care (a level of care needed by a resident who does not require hospital acute care but who requires more intensive licensed skilled nursing care than is provided to the majority of patients in a skilled nursing facility) unit.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the ventilators (vent -a medical device that helps a patient breathe), for eight of 12 residents, Residents 1, 2, 3, 4, 5, 6, 7, and 8, were serviced by the due dates indicated on the label at the back of the vents and according to the manufacturer ' s recommendation. This failure had the potential to result in Residents 1, 2, 3, 4, 5, 6, 7, and 8 ' s increased risk for infection and improper ventilation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for 12 of 14 residents, Residents 2, 3, 4, 5, 6, 8, 9, 10, 11, 12, 13 and 14, infection control practices where in place when multiple respiratory equipment was not changed and dated according to the facility ' s policy and procedure.

Inspectors wroteBased on interview and record review, the facility failed to timely (within three months) complete the quarterly MDS (Minimum Data Set - an assessment tool used to evaluate the health status of nursing home residents) assessment for six of 81 residents still in the facility (Residents 57, 14, 38, 28, 30 and 35). This failure had the potential to negatively impact the residents' quality of care and had the potential for staff to not be aware of the residents' care needs and provide appropriate treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the accountability of controlled medications (those with high potential for abuse and addiction) and the appropriate use of pain medications when: 1. The Controlled Drug Records (accountability records, an inventory sheet that keeps records of the usage of controlled medications) for five of six residents reviewed (Residents 7, 53, 54, 68, and 70) did not reconcile with the Medication Administration Records (MAR). This failure resulted in inaccurate accountability and the potential for abuse and diversion of controlled medications; and 2. Nursing staff failed to administer one medication as ordered by the prescriber for one of five residents reviewed (Resident 70). This failure resulted in Resident 70 receiving a dose of pain medication without the appropriate indication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1a. One half gallon carton of Mocha Mix in the number two reach-in refrigerator did not have a use-by-date and was readily available for use; 1b. One Ziploc bag containing shredded carrots in the number three reach-in refrigerator did not have a use-by-date; and 2. One four ounce orange sherbet container and black residue were observed on the floor behind the freezer racks of the walk-in freezer. These failures had the potential to cause foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, and toxins) in vulnerable and medically compromised residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event) was identified timely and the trauma informed practices and care plan were implemented for one of one resident reviewed (Resident 70). This failure resulted in Resident 70's verbalization of feeling sad and resulted in his mental and psychosocial needs not being met by the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five residents reviewed (Resident 196) was free of unnecessary medications when pain assessments were not documented with the administration of pain medications. This failure had the potential for unnecessary or ineffective pain management for Resident 196.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Certified Nursing Assistant (CNA) 1 did not wear personal protective equipment (PPE - equipment used to protect against infection or illness) when taking care of a resident (Resident 43) on enhanced barrier precautions (EBP - an infection control intervention designed to reduce transmission of multidrug resistant organisms in nursing homes); 2. The facility failed to place a resident (Resident 50) on EBP who had an indwelling urinary catheter (a tube placed in the body to drain and collect urine from the bladder); and 3. The facility failed to place a resident (Resident 248) on EBP who had a gastrostomy tube (a feeding tube through the skin and the stomach wall). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the needs for one of three sampled residents (Resident 2), when the call light button was observed not within reach. This failure had the potential for Resident 2 not to be able to call staff for assistance which could result in unmet resident's needs.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was assessed timely following an unwitnessed fall. The facility also failed to provide notification to the physician following an unwitnessed fall. This failure had the potential for Resident 1 to experience a delay in the provision of care and complications such as, pain, bruising, scratches, lacerations (a deep cut or tear in skin), and fractures (a complete or partial break in a bone).

Inspectors wroteBased on interview and record review, the facility failed to provide resident with an alternative meal, consistent with resident's identified food allergies, for 1 out of 5 residents (Resident 1). This failure could have negatively impacted Resident 1's health by consuming a food item they had an allergy to.

Inspectors wroteBased on observation, interview, and record review, the facility failed to document ventilator alarm checks every 4 hours, on the ventilator flow sheets, as specified in the facility ' s policy and procedure, Mechanical Ventilation, for 3 out of 3 residents. This failure could have resulted in facility staff to be unaware of a ventilated resident ' s respiratory decline or faulty ventilator setting.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two residents were treated with dignity and respect, when Certified Nursing Assistant (CNA) 1 made disrespectful comments and gestures towards Resident 1 and 2. This failure resulted in not ensuring residents' rights to be treated with dignity and respect and could potentially result in negative psychosocial outcomes, such as changes in mood and/or behavior.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared, stored, served, or distributed in accordance with professional standards of food service safety when: 1. Several food items were stored in the refrigerator past their use-by date and readily available for use; 2. Three cans of Vegalene (brand name for vegetable oil spray) oil spray did not have caps and were not labeled with the use-by date and readily available for use; 3. Several fresh fruit and vegetables were stored in zip lock bags which were not properly labeled and readily available for use; 4. The drain pipe behind the ice machine had thick black residue, and the metal back and side panels of the ice machine were dirty and rusty at the bottom. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and implement infection prevention and control practices for seven of 18 residents reviewed (Residents 16, 30, 37, 48, 57, 66, and 281) when: 1. For Residents 16, 30, 37, 48, 57, and 66, the indwelling Foley catheter (a tube inserted into the bladder to drain the urine held in place by a small balloon) bags were observed on the floor; and 2. For Resident 281 the Licensed Vocational Nurse (LVN) 1 did not perform hand hygiene before providing treatment. These failures had the potential to expose the identified vulnerable residents to infection and to the development and transmission of communicable diseases.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' representatives (RR-individual who is responsible or legally responsible to make decisions for the resident who cannot make their own decisions) were provided with written information and offered assistance in formulating an Advance Directive (AD-written instructions on the provision of medical care and treatment in the event the person was not able to make decisions) for three of 13 residents reviewed (Residents 21, 37, and 57). This failure had the potential for Residents 21, 37, and 57, to receive care, treatment, and services not in accordance with the residents' best interest and wishes.

Inspectors wroteBased on interview, and record review, the facility failed to meet the needs for four of four residents reviewed. (Residents 34, 59, 63, and 280) when: 1. The facility's policies and procedures were not implemented to accurately account for the doses of controlled substances removed from the medication cart and the doses administered to the residents; 2. One discontinued controlled substance medication was stored in the medication cart along with other active medications; and 3. One medication was administered to the resident from the manufacturer's original bottle that did not have a readable expiration date. These had the potential for drug diversion by staff caring for the residents, and wrong and ineffective medications to be administered to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, for one resident reviewed for environment (Resident 4), the bed was in good working condition. This failure had the potential for Resident 4 to not be properly positioned in bed aggravating her discomfort, and could lead to accidental falls from slipping.

Inspectors wroteBased on observation, interview, and record review, for one of 21 residents (Resident 85) the facility failed to provide assistance to feed resident the breakfast meal in a timely manner. Resident 85 waited approximately one hour to be fed. This failure had the potential to result in Resident 85 having feelings of not being cared for with dignity and respect when other residents were eating.

Inspectors wroteBased on observation, interview, and record review, the facility failed for one of 21 residents reviewed (Resident 9) to ensure the two eyedrop solution bottles were not left on the bedside table. This failure had the potential to unsafe administration of the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed, for one of 21 residents reviewed (Residents 58), to ensure the licensed nurses assessed, monitored, and referred to the physician the multiple bluish and reddish skin discoloration identified on the resident's bilateral arms on September 8, 2019. This failure had the potential for the resident to not be monitored for complications related to the multiple skin discolorations such as bleeding, skin tears, and infection.

Inspectors wroteBased on observation, interview and record review, the facility failed for one of one resident (Resident 189) reviewed for bowel and bladder (B&B) continence (ability to control movements of bowel and urine), to ensure the resident was monitored and evaluated 72 hours upon admission if the resident was a possible candidate for B&B individualized training or scheduled voiding (toileting schedule in which the nurse bring the resident to the bathroom at a certain time for toileting purpose to help prevent incontinence {inability to control movement of bowel and urine}), and restore the highest B&B functioning level. This failure had the potential for a decline in Resident 189's bowel and bladder function.

Inspectors wroteBased on interview and record review, for one of five residents, Resident 76, reviewed for unnecessary medications, the facility failed to address and clarify the pharmacist's recommendation for the medication Risperidone (a drug used to treat mental, mood disorders). This failure prevented the facility to protect Resident 76 from a potential irregularity in the administration of the drug Risperidone for Resident 76.

Inspectors wroteBased on interview and record review for two of seven residents reviewed (Residents 190 and 191) for unnecessary use of medications, the facility failed to ensure: 1.a For Resident 190, an assessment upon admission was conducted to evaluate the need for the continued use of Seroquel (medication used to treat behavioral problem), buspirone (medication used to treat anxiety), and sertraline (medication used to treat depression); and 1b. Resident 190 was monitored for the effectiveness of Seroquel and the adverse side effects of buspirone upon admission; and 2. For Resident 191, an assessment upon admission was conducted to evaluate the need for the continued use of Ativan (medication used to treat anxiety) and escitalopram (medication used to treat depression). These failures had the potential for the residents to use unnecessary medications.