Premier Care Center for Palm Springs

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accident hazards were identified and removed from the resident environment, for one of three sampled resident (Resident 1), when an extension cord not authorized by the facility for resident's use was used to plugged several electrical items This failure resulted in an electrical fire involving the resident's bed requiring activation of the fire alarm, response by the Fire Department, evacuation of nearby residents, and Resident 1's transfer to the emergency department for evaluation following potential smoke exposure. FindingsOn June 25, 2026, at 10:30 a.m., during a concurrent observation and interview with the Maintenance Director (MAIND), the MAIND stated the following:- He received a call from the Director of Staff Development (DSD) at approximately 6 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care and treatment was provided, for 12 of 93 residents (Residents 113, 4, 12, 9, 69, 5, 89, 116, 87, 109, 84, and 119), when:1. For Resident 113, the facility did not conduct on-going assessment of the resident's bowel movement/constipation (difficulty passing stool) and implement interventions to address constipation according to the physician's order and facility's policy and procedure, when Resident 113 did not have bowel movement from February 4, 2026, to February 10, 2026 (seven days). In addition, the facility staff did not act on several daily alert notifications from February 6, 2026, to February 11, 2026, indicating Resident 113 not having a bowel movement (BM) for more than three days.2. [...]

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, for 92 of 93 residents who received food from the facility kitchen, when the following were found, readily available for use:1. Several bottles of opened herbs and spices were found not labeled with open dates;2. One opened one-gallon container of buttermilk ranch dressing and one opened one-gallon container of egg mayonnaise were found inside refrigerator # (number) 1 without open dates;3. One package of roast beef was found stored in the walk-in refrigerator, past its use-by date; and4. One opened one-gallon container of sesame oil was not labeled with an open date. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an individualized comprehensive care plan was developed, for seven of 23 residents reviewed (Residents 8, 25, 109, 119, 32, 89, and 116), when:1. For Resident 8, a care plan was not developed to address targeted behavior of hallucinations (a false perception or sensory experience -such as seeing, hearing, smelling, tasting, or touching something that is not actually present), depression (common, serious, and treatable mental health disorder characterized by persistent feelings of extreme sadness, emptiness, hopelessness, and a loss of interest in activities), and anxiety (a common, often normal, feeling of intense fear, dread, and nervousness);2. For Residents 25, 109, and 119, a care plan was not developed to address dental issues; and3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility's policy and procedure on oxygen use was followed, for three of three residents reviewed under oxygen (Residents 32, 89, and 116, when:1. For Residents 32 and 89, the nasal cannula (a medical device used to deliver supplemental oxygen) was not changed every seven days; and2. For Resident 116, the nasal cannula was undated when it was initially used. These failures had the potential to result in risk for infection for Residents 32, 89, and 116.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmacy services were implemented according to the facility's policy and procedure, when:1. One vial of shingles (a painful viral infection causing a blistering rash, usually in a stripe on one side of the body or face) vaccine labeled for Resident 19, dispensed by pharmacy on February 19, 2026, and stored in the medication refrigerator available for use, despite complete dose of shingles vaccine received by Resident 19 prior to February 19, 2026. This failure had the potential for duplicate administration of shingles vaccine to Resident 19 and could cause adverse effect of the medication; and2. PRN (as needed) narcotic medications were administered and documented in accordance with the physician orders and the facility policy and procedure for Residents, 12, 24, and 23. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored properly according to the facility's policy and procedure, when:1. One vial of IV (intravenous- through the veins) medication was stored together with oral medications;2. Eye drop medications were stored together with oral medications. These failures had the potential for the medications to be administered through the wrong route; and3. Discontinued or completed treatment medications were stored in the Treatment Carts readily available for use. In addition, one opened box of iodine prep pads, which expired in February 2025, was stored in the treatment cart readily available for use. These failures had the potential for the medications to be administered to the residents without physician's orders and could have adverse effect on the residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dental care services and follow up treatment were provided, for three of five residents reviewed for dental (Residents 25, 109, and 119), when:1. For Resident 25, there was no follow up dental consult after denture impressions were obtained on October 5, 2025;2. For Resident 109, there were no dental services/consult provided for broken, missing, and carious teeth; and3. For Resident 119, there were no dental services/consult provided for missing teeth or ill-fitting dentures. These failures had the potential to result in untreated dental conditions, pain, infection, poor nutrition, and further decline in overall health.

Inspectors wroteBased on interview and record review, the facility's Administrator and governing body failed to ensure a Quality Assurance Performance Improvement (QAPI - as systematic, interdisciplinary, comprehensive, and data-driven approach to maintain and improve safety, quality of care, and quality of life of the residents) plan was in place to address the facility's systemic process issues related to addressing constipation through the facility's bowel management program. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure infection control practices were implemented according to facility policy and procedure and standards of practice for three of 93 residents (Residents 49, 37, and 77) when:1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents are free from unnecessary use of psychotropic (therapeutic drugs that affect brain function, altering mood, perception, cognition, and behavior to treat mental health disorder) medications, for one of five residents reviewed for unnecessary medications (Resident 8), when:1. The reason for PRN (as needed) Lorazepam (medication to treat anxiety) was documented and non-pharmacologic interventions were provided to Resident 8 prior to administration of PRN Ativan; and2. There was no informed consent obtained by the physician from the resident/resident representative regarding the use of Mirtazapine (medication to treat depression). These failures had the potential for Resident 8 to receive unnecessary psychotropic medications and could develop adverse effects from the use of psychotropic medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the necessary process when a resident is to be discharged was implemented according to the facility's policy and procedure, for two of three residents reviewed under closed records (Resident 114 and 112), when:1. For Resident 114, a written notice of proposed transfer (a written notification which included the contact information for the Long-Term Ombudsman [a trained advocate-either a staff member or volunteer-who investigates complaints and resolves problems regarding the health, safety, welfare, and rights of individuals living in nursing homes, assisted living, and board and care facilities] and appeal rights) was provided to the resident timely. This failure had the potential for Resident 114 to be not aware of his appeal rights for inappropriate discharge; and2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed ensure cigarettes and smoking paraphernalia were kept secured in a locked container in the nursing station, according to the plan of care and facility's policy and procedures, for one of two residents reviewed for smoking (Resident 123). This failure had the potential to place Resident 123 and other residents at risk of harm and injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure essential items necessary for hydration were in reach, for two of two residents reviewed for hydration (Residents 12 and 17), when the residents' water pitchers were observed out of reach. This failure had the potential to result in compromised hydration, impaired skin integrity, and increased risk for falls.

Inspectors wroteBased on interview, and record review, the facility failed to ensure pain medications were administered according to the physician's order, for two of three residents reviewed under pain (Residents 12 and 62). This failure had the potential for Residents 12 and 62's pain not to be managed appropriately.

Inspectors wroteBased on interview and record review, the facility failed to ensure required physician visits and ongoing medical oversight was conducted, for one of one resident reviewed (Resident 17), when there was no documented evidence of a physician visit for 2025. This failure had the potential to place the resident at risk for unidentified changes in medical condition, outdated treatment plans and medication-related complications. ce the resident at risk for unidentified changes in medical condition, outdated treatment plans and medication-related complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure abnormal laboratory result was referred to the physician, for one of 23 residents reviewed (Resident 11), when the potassium (an essential mineral and electrolyte crucial for maintaining healthy blood pressure, heart function, nerve signals, and muscle contractions) level was 3.2 (normal range of 3.5 to 5.1). This failure had the potential for delayed care and treatment and could affect Resident 11's overall health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fortified diet (having had vitamins or other supplements added to increase the nutritional value) was provided as ordered by the physician and according to the facility's diet menu spreadsheet, for one of 14 residents with fortified diet order (Resident 44). This failure had the potential for Resident 44 not to receive the required dietary nutrients and could lead to weight loss and affect overall health condition of the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food at appropriate temperatures when served to the residents according to the facility's policy and procedure, for two of two residents (Residents 32 and 5), when the milk and salad's temperature were above the recommended temperature when served. This failure placed residents at risk to decrease their oral intake and affect the residents' nutritional status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Infection Preventionist (IP) implemented the antibiotic stewardship program, for one of 93 residents reviewed (Resident 84), when the IP did not review multiple antibiotics that were prescribed for Resident 84. This failure had the potential to place Resident 84 at risk for complications related to prolonged antibiotic use, adverse drug reactions, and development of antibiotic-resistant organisms.

Inspectors wroteBased on interview and record review, the facility failed to ensure influenza vaccine (an annual vaccine that protects against influenza [a contagious respiratory illness] by helping the body produce antibodies) was received after obtaining consent on January 26, 2026, according to the facility's policy and procedure, for one of five residents reviewed for immunization (Resident 88). This failure had the potential for Resident 88 to be at risk of acquiring influenza and increase the risk of experiencing complications related to it.

Inspectors wroteBased on interview and record review the facility failed to ensure interventions to reduce the risk of falls were evaluated for effectiveness and modified to address multiple falls, for one of five residents reviewed (Resident A). This failure resulted in Resident A to experience multiple falls and had the potential for the resident to have repeat falls and sustain injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection prevention and control standards was implemented to provide a safe and sanitary environment, when the HVAC (heating, ventilation, air conditioning) units filter were not changed according to the facility's policy and procedure and national infection control guidelines. This failure had the potential to result in residents who test positive for a respiratory disease to spread the illness to other residents in rooms which share the same ventilation system.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure environmental conditions were being monitored and maintained in a safe and functional manner for the residents and staff, when:1. The exit door was left open. This failure had the potential for the residents to get out of the facility without the knowledge of the facility staff. In addition, the maintenance shop door was left open and unattended. This failure had the potential for unauthorized staff and residents to have access to the the maintenance room and get materials that could have harm them or others; 2. The generator (used as a backup system if a facility loses electrical power) was not being tested according to the facility's policy and procedure. This failure had the potential for power to not be supplied to the facility in case of power outage; and3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control interventions and treatments to help decrease the spread of scabies (a contagious skin infestation caused by the microscopic mite, which burrows into the upper layer of skin to live and lay eggs, characterized by intense, nocturnal itching and a pimple-like rash), for one of five residents (Resident 1), when:1. The dermatologist's (a doctor who specializes in skin issues) orders for Permethrin (a topical medication to treat scabies) was not administered as ordered;2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an evaluation of elevated blood pressure and notification to the physician was conducted, for one of three residents reviewed (Resident 1). This failure had the potential for a delay in the care and treatment of Resident 1's uncontrolled hypertension (high blood pressure) and had the potential to experience complications related to high blood pressure.

Inspectors wroteBased on interview and record review, for one of three residents reviewed (Resident 1), the facility failed to ensure:1. A physician's order was obtained to discontinue or remove a urinary catheter prior to removal of the catheter; and 2. Monitoring and documentation of the resident's urine output, any signs and symptoms of pain and/or bladder distention, after the urinary catheter was removed. These failures had the potential for a delay in the care and treatment to address possible adverse effects from removal of the catheter.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a complete pain assessment was conducted, which included the location of pain, for one out of three residents (Resident 1). This failure had the potential for Resident 1's pain not to be managed effectively.

Inspectors wroteBased on interview and record review, the facility failed to ensure proper monitoring and neurological assessments (used to monitor patients, checking mental status, nerves, reflexes and motor function) were completed, for one of three residents (Resident A). This failure had the potential to cause delay in care and treatment for Resident A following an unwitnessed fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, for five of five residents reviewed (Residents 1, 4, 5, 6, and 7) received medications timely, when Residents 1, 4, 5, 6, and 7 ' s scheduled 9 a.m. medications were administered to the residents passed the required timeframe. This failure had the potential for the residents to experience discomfort, and a delay in the intended therapeutic effect of the medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure a registered nurse (RN) was scheduled for eight consecutive hours in a 24-hour period for November 3, 10, 16, 23, 24, 30, 2024 and December 7, 8, 15, 21, 22, 29, 2024. This facility failure had the potential to result in delayed identification and treatment of life-threatening medical conditions thus compromising the health and safety of the vulnerable population in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat resident with respect and dignity when the staff failed to cover the urinary bag, for one of one resident reviewed (Resident 2). This failure increased the potential to negatively affect Resident 2's psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (device that produce a tone and light) was available for the resident to use and call for assistance, for one of two residents reviewed (Resident 2). This failure had the potential to result in the resident being unable to call for staff assistance when needed.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents was free from verbal abuse, for one of five residents reviewed (Resident 5), when the Certified Nurse Assistant Student (CNAS) called Resident 5 an inappropriate word. This failure had the potential for Resident 5 to experience emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of verbal abuse by a Certified Nursing Assistant Student (CNAS) towards a resident to the California Department of Public Health (CDPH) immediately or within 2 hours after the allegation was made, for one of five residents (Resident 5). This failure had the potential to result in further abuse for Resident 5, affecting the resident's emotional, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of verbal abuse by a Certified Nursing Assistant Student (CNAS) towards a resident to the California Department of Public Health (CDPH) immediately or within 2 hours after the allegation was made, for one of five residents (Resident 5). This failure had the potential to result in further abuse for Resident 5, affecting the resident's emotional, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nutritional care and services were provided, for one of three sampled residents reviewed (Resident 7), when the nutritional recommendations of the Registered Dietitian (RD) to address Resident 7's significant weight loss were not followed. This failure resulted to Resident 7 not receiving the interventions to address resident's weight loss. In addition, this failure had the potential to result for further weight loss on Resident 7.

Inspectors wroteBased on interview and record review, the facility failed to address or update care plans with measurable goals and interventions to address gastrointestinal (GI) symptoms (nausea, vomiting, and diarrhea), for four of nine residents (Resident 1, 2, 6, 21). This failure had the potential for the staff not to be aware of the interventions implemented to address the residents' GI symptoms.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure infection control practices to control and manage gastrointestinal outbreak (GI outbreak - occurs when there are more cases of vomiting or diarrhea than expected in a given place or time) according to the facility's policy and procedure and CDC (Centers for Disease Prevention and Control) guidelines were implemented, when: 1. The facility staff did not perform hand hygiene after having contact with high-touch areas; 2. The facility staff did not wear the appropriate PPE (personal protective equipment - protective clothing or equipment designed to protect the wearer's body from infection) while providing care to a resident requiring Enhanced Barrier Precautions (EBP - a set of infection control measures that use of PPE to reduce the spread of infections); and 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an assessment for safe self administration of medication was conducted, for three of 21 residents (Residents 38, 42, and 77) when: 1. One opened bottle of 15 ml (milliliter - unit of measurement) eyedrops (medication that relieves eye irritation) was found on the overbed table of Resident 38; 2. One opened respiratory inhaler medication (a handheld device that delivers medication directly to the lungs through breathing) of albuterol HFA (brand name) 108 mcg/act (microgram/actuation - unit of measurement) was found on the overbed table of Resident 42; and 3. One opened glass container of Muscle Balm pain relieving ointment (brand of ointment) 18 g (gram-unit of measurement) was found on the overbed table of Resident 77. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, for three of 21 residents reviewed (Residents 28, 33, and 88): 1a. For Resident 28, the medication Lisinopril and Metoprolol (medications to treat high blood pressure) was not held according to the physician's order. In addition, the medication Midodrine (medication to treat low blood pressure) was not administered according to the physician's order. This failure had a potential for Resident 28 to have low blood pressure and could affect overall health condition; 1b. For Resident 28, there was no follow up assessment and monitoring after the resident was readmitted from the hospital on July 23, 29, and August 6, 2024. This failure had the potential for any changes in Resident 28's condition to be unidentified and could have a delay in the care and treatment; 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered as prescribed by the physician to meet the needs of the residents, when: 1. During a medication pass observation, a wrong dose of fluticasone (medication used for nasal congestion) nasal spray was administered, for one of five residents observed (Resident 65); 2. Four doses of an IV (intravenous; into vein) antibiotic medication was not administered in November 2024 without a reason documented in the medical record, for one of five residents reviewed (Resident 191); 3. For one of five residents reviewed (Resident 11), one blood pressure medication was held without properly documenting the reason for not administering the dose in accordance with the parameters ordered by the physician; 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure special dietary needs were provided, for three residents reviewed during the lunch meal preparation on November 15, 2024, (Residents 46, 76, and 192) . This failure had the potential to place residents at risk of not having their nutritional and dietary needs met.

Inspectors wroteBased on observation, interview and record review, the facility failed to store food in accordance with professional standards for food service safety, when multiple residents' food items were stored in the nurses' station refrigerator undated and out of date. This failure had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed these foods in the facility.

Inspectors wroteBased on observation, interview, and facility record review, the facility failed to maintain infection control practices when: 1. Resident 65 was observed in the dining room with his urinal hanging from the back of his wheelchair; and 2. One staff was observed not wearing the appropriate N95 respirator mask (disposable filtering device respirator) when providing care to COVID-19 (corona virus - a contagious respiratory disease) positive residents. These failures had the potential to spread infectious disease to other residents and staff in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (device that produce a tone and light up indicating the location of the call, used by the residents to signal a need for assistance from facility staff) was answered promptly, for one of 93 sampled residents (Resident 9). This failure increased the potential for delayed nursing and medical management, as well as actual unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure a copy of the Advance Directive (AD - a written instruction, such as a living will, relating to the provision of treatment and services when the individual becomes unable to decide) was available in the medical record, for one of seven residents reviewed for Advance Directives (Resident 11). This failure had the potential to result in Resident 11's wishes related to the provision of medical treatment and services to not be followed, if Resident 11 became unable to make decisions for himself.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and comfortable homelike environment, for one of six residents reviewed for environment (Resident 86) when the chair rail molding above the resident's bed was detached and damaged from the wall. This failure had the potential for Resident 86 to experience lack of sleep, discomfort, and irritability, which could affect the resident's overall health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, for one of one resident reviewed for ADL (Activities of Daily Living) was provided nail care (Resident 9). This failure prevented the resident from receiving maintaining proper grooming and personal hygiene.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper storage of medications did not include unusable, expired medications when: 1. There were two expired daptomycin (antibiotic) IVPB (intravenous piggyback; a method of administering IV antibiotics by piggybacking it to a primary IV fluids) stored in the medication refrigerator for Resident 82; 2. There was one discontinued medication for Resident 35 in the medication cart along with other active medications; and 3. There was one injectable insulin (medication to control blood sugar) pen without an open date or expiration date in the medication cart. These failures had the potential for residents to receive expired and ineffective medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a comfortable environment, for one of four residents (Resident 38) when water was leaking from the pipe under the sink, forming a puddle of water on the floor. This failure resulted in the resident feeling uncomfortable and disrupted the resident's daily living needs and environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's meal intake was accurately documented, for one of three residents reviewed (Resident 1), when the facility did not document Resident 1's meal intake for multiple days. This failure had the potential to result in inaccurate nutrition assessments and a delay in the care and services to address nutrition issues for Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure changes in the residents's medication by hospice (a type of care that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to their emotional spiritual needs at the end of life) was communicated to the facility for implementation, for one out of three sampled residents, when the order for albuterol sulfate inhalation (medication used to prevent and treat wheezing and shortness of breath caused by breathing problems) to be given every four hours routine was not carried out as ordered. This failure resulted to the resident not receiving the medication to aid in treating breathing problems and had the potential for the resident to not receive the full treatment to relieve him from breathing difficulty.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient preparation for a safe orderly discharge on [DATE], for one (Resident 3) of five sampled residents. This failure increased the risk for Resident 3 not to receive the needed care and could result in rehospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure: 1. Resident 1 was given pain medication (Norco/Hydrocodone Acetaminophen [combination medication is used to relieve moderate to severe pain]) in accordance with the physician order on December 19, 2023. This failure could have contributed to the resident being sedated which resulted in the resident's transfer to the general acute care hospital. 2. Resident 2 was given insulin in accordance with the physician order. In addition, the facility did not ensure a clear hypoglycemia management protocol was in place to address Resident 2's hypoglycemic episode on December 15, 2023. These failures have the potential to result in complication which can further worsen Resident 2's already compromised health condition.

Inspectors wroteBased on interview and record review, the facility failed to reduce the risk of falls for one of three sampled residents (Resident 1) when the facility did not accurately assess the resident's risk of falls. This failure placed Resident 1 at risk for falls and jeopardized the health and safety of Resident 1.

Inspectors wroteBased on interview and record review the facility failed to provide rehabilitation services per physician order for one of three sampled residents (Resident 1) when the facility did not provide skilled therapy evaluations as ordered. This failure had the potential to result in Resident 1 to not maintain his highest level of function.

Inspectors wroteBased on interview and record review the facility failed to follow an advanced health care directive (ACHD) for one of three sampled residents when the facility allowed a resident, who had a healthcare agent, to self-discharge from the facility. This failure violated the rights of Resident 1's representative and had the potential to endanger the health and safety of Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an allegation of sexual abuse involving a resident (unknown) towards Resident A was reported to the California Department of Public Health (CDPH) immediately, or not later than two hours after the allegation was made. This failure had the potential to result in the delay in implementation of appropriate action and provision of protection to the resident and placed the resident at risk for further abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care and treatment was provided, for three of 18 residents reviewed (Residents 28, 34, and 175), when: 1. For Resident 28, the dark purple skin discoloration on the resident's left upper inner arm measuring approximately 6.8 centimeters (cm - unit of measurement) by (x) 9.5 cm in size was not identified and addressed; 2. For Resident 34, a skin infection on the resident's left middle finger was not identified and addressed; and 3. For Resident 175, there was no assessment conducted to evaluate the effectiveness of the Nystatin Suspension (medication used to treat oral thrush {fungal infection of the mouth}) after the treatment was completed on December 31, 2022. In addition, there was no care plan initiated to address the oral thrush. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were administered as prescribed by the physician, for two of 18 residents reviewed (Residents 14 and 60), when: 1. For Resident 14, Midodrine (a medication used to increase blood pressure) was not held according to the physician's order; and 2. For Resident 60, pain medication was not administered according to the physician's order. These failures resulted to Residents 14 and 60 to receive medications inappropriately and had the potential for them to experience adverse effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure storage, preparation, and distribution of food were in accordance with professional standards for food service safety, when: 1. Kitchen areas, storages, and equipments were found with debris, discolorations, and residue; one storage room found with trash and one dead cock roach; and cooking utensils were found to have cracks and chips. 2. Resident's refrigerator was found to have food item and beverages that were not labeled accordingly. 3. A dietary staff was observed not practicing proper infection control when preparing food. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication was received with a physician's order, for one of 18 sampled residents (Resident 63). This failure had the potential for Resident 63 to receive medication with no appropriate monitoring for medication effectiveness and side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an eye consultation and/or referral to eye specialist was arranged and provided, for two of two residents reviewed for vision (Residents 62 and 28). This failure had the potential for the residents to experience a delay of treatment which may result in the decline of their eyesight.

Inspectors wroteBased on interview and record review, the facility failed to ensure the psychotropic medication had an appropriate indication for use, for one out of five residents reviewed for unnecessary medications (Resident 14). In addition, the facility failed to monitor a specific behavior related to the use of the psychotropic medication for Resident 14. This failure had the potential for Resident 14 to receive unnecessary medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication was stored according to the facility's policy and procedure, for one of 70 residents (Resident 377), when one packet of Thera Body Calazinc Body cream (medicated cream used to treat skin irritations, also used as a skin protectant) was found unsecured on top of the resident's overbed table. This failure increased the possibility for Resident 377 to receive medication unsafely and had the potential for other residents to have access to the medication and administer it unsafely.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the food service personnel safely and effectively carried out the functions of food and nutrition service, when the Dietary Aide (DA) did not follow the manufacturer's recommended timeframe for testing the Quaternary ammonium (Quat) sanitizer solution (sanitizer solution used for removing bacteria and viruses in the kitchen). This failure had the potential for the Quat solution to not be tested within the right concentration level and could cause foodborne illness (stomach illness acquired from ingesting contaminated food), for 66 out of 70 sampled residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' food preferences were honored, for two of 66 sampled residents (Residents 275 and 70), when: 1. Resident 275 was served milk despite the meal tray ticket indicating no milk to drink; and 2. Resident 70 was not served double portion of vegetables as requested. These failures had the potential to result in decreased food intake, and further compromising Resident 70 and 275's nutritional and medical status.