Palm Springs Healthcare & Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: On December 9, 2024, at 4 p.m., Resident 70 was observed sitting upright in his bed awake, alert, and able to verbalize his needs. Resident 70 verbalized the past history of trauma in his life. He was asking to talk to someone in regards to his feelings and about his PTSD. On December 10, 2024, Resident 70's record was reviewed. Resident 70 was admitted to the facility on [DATE], with diagnoses which included Chronic Obstructive Pulmonary Disease(COPD- lung disease). The history and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings: Resident 196 had a physician order, dated December 6, 2024, for hydrocodone with acetaminophen (Norco, a controlled medication for pain) 5-325 milligrams (mg), one tablet by mouth every four hours as needed for Moderate pain 4-6 Severe pain 7-10. A review of Resident 196's December 2024 Medication Administration Record (MAR) indicated Resident 196 received a dose of Norco 5-325 mg on the following dates and times: - December 7, 2024, at 10:12 a.m.; - December 8, 2024, at 10:03 p.m.; - December 10, 2024, at 8:54 p.m.; and - December 11, 2024, at 8:27 a.m. The record did not indicate the pain rating scale (pain score, numerical value between zero and 10, where zero means no pain and 10 means severe pain) and pain assessment before or after the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). These failures had the potential to increase the spread of multidrug resistant organisms and infections from staff to residents which could lead to illness or death. Findings: 1. On December 9, 2024, at 11:13 a.m.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: On September 4, 2024, at 9:45 a.m., during an observation and concurrent interview with Resident 2, the resident's call light button was observed hanging on the wall behind the resident's bed. Resident 2 stated he was not sure where the call light was. On September 4, 2024, at 10:02 a.m., an observation and concurrent interview was conducted with Certified Nursing Assistant (CNA) 1, CNA 1 agreed the resident (Resident 34) was not able to reach the call light, and the call light should be within reach. CNA 1 stated that the call light should not be hanging on the wall behind the bed. CNA 1 further stated Resident 2 can fall or not be able to get assistance and he…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). Findings: On September 4, 2024, at 8:45 a.m., an unannounced visit was conducted at the facility to investigate a facility reported incident. Resident 1 was unavailable for an interview or observation due to being transferred out of the facility to a general acute care hospital (GACH) on August 18, 2024. A review of Resident 1's facility medical record indicated she was admitted to the facility on [DATE], with diagnoses that included osteoporosis (causes bones to become weak and brittle), cerebral infarction (stroke)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: On May 7, 2024, at 7:55 a.m., an unannounced visit was made to the facility to investigate a quality-of-care issue. On May 7, 2024, at 8:20 a.m., an interview was conducted with Resident 1, who stated, her food allergies are peanuts and tomatoes. Resident further stated, she requested a tuna sandwich from nursing staff, and nursing staff brought her a tuna sandwich with tomatoes on it. Resident 1 informed nursing staff she was allergic to tomatoes, and she could not eat it. Nursing staff returned resident's sandwich and brought her a new tuna sandwich with no tomatoes on it. A review of Resident 1's face sheet, indicated, resident was admitted to the facility on [DATE], with a diagnosis of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: On [DATE], at 12:00 p.m., an unannounced visit was made to the facility for a Quality-of-Care issue. 1) A review of Resident 1 ' s SBAR (Situation, Backround, Assessment, Recommendations), dated, [DATE], at 11:34, by RN 1, stated, . LN (Licensed Nurse) reported to RN (Registered Nurse) that (Resident 1) is unresponsive. Upon assessment, (Resident 1) was unresponsive, blue color, no pulse. Code blue called and CPR (Cardio-Pulmonary Resuscitation, life saving measures) was initiated and called 911 . Review of Resident1 ' s face sheet, indicated, resident was admitted to the facility on [DATE], with a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: 1. On July 20, 2023, at 10:40 a.m., during an interview, Resident 3 stated she heard the conversation between CNA 1 and Resident 1 on July 11, 2023, while CNA 1 was providing care to Resident 1. Resident 3 stated CNA 1 said look at that fat, referring to her roommates body. Resident 3 stated CNA 1's comments made her uncomfortable. On July 20, 2023, at 12:12 p.m., an interview with CNA 2 was conducted. CNA 2 stated Resident 1 told him CNA 1 made her feel uncomfortable, by making statements that she was too fat. Resident 1 said to CNA 2 that CNA 1 made her feel…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. These failures had the potential to cause food-borne illness in a highly susceptible population of 54 out of 82 residents who could consume food. Findings: 1. a. During a concurrent observation of the reach-in refrigerator with Dietary Aide (DA) 1 on June 5, 2023 at 9:45 a.m., one carton of Darigold Fit lactose free, reduced fat,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: 1. a. On June 7, 2023, at 11:12 a.m., Resident 16, was observed awake, nonverbal, with a tracheostomy (an incision in the windpipe to allow air to fill the lungs) tube attached to a ventilator (a machine used to move air in and out of the lung), a gastrostomy tube (a tube inserted into the stomach for the delivery of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: 1. On June 5, 2023, at 10:10 a.m., Resident 21, was observed awake watching television. Resident 21 was able to respond by nodding his head for approval. Resident 21 had a tracheostomy (an incision in the windpipe to allow air to fill the lungs) tube attached to a ventilator (a machine used to move air in and out of the lungs), a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings: 1. On June 6, 2023, at 3:40 p.m., during the medication cart inspection in the Desert Wing Nursing Station with Licensed Vocational Nurse (LVN) 1 , blister cards containing controlled substances (CS's) stored in the cart were audited to determine the accuracy of CS accountability. Two residents CS's that were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: On June 6, 2023, at 11:01 a.m., Resident 4 was observed awake, lying supine in bed, slightly turned to her left side, with the head of the bed raised at approximately a 45 degree angle. Resident 4 stated her bottom hurt. Certified Nursing Assistant (CNA) 1 was observed to respond to Resident 4 and attempted to reposition her in bed. CNA 1 attempted to lower the head of the bed, but it would not go down. CNA 1 attempted a few times to adjust the bed but the head of the bed remained in place. CNA 1 stated the bed had not worked since a week ago, had been reported to maintenance to fix, and had been written in the maintenance log at the nurses' station. On June 8, 2023, at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: On September 9, 2019, at 08:44 a.m., an observation and interview was conducted with the Minimum Data Set (MDS)-Licensed Vocational (LVN). Resident 85's breakfast tray was observed on top of the bedside table. There was no facility staff observed providing feeding assistance to Resident 85. The MDS-LVN stated Resident 85 was not assisted to eat her breakfast meal. The MDS-LVN stated breakfast trays were brought out and served approximately 8 a.m., in Resident 85 hallway. A concurrent interview was conducted with Resident 85. Resident 85 was asked if she was hungry and wanted to eat breakfast, Resident 85 noded her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: On September 8, 2019, at 9:04 a.m., an observation and a concurrent interview was conducted with Resident 9 and Registered Nurse (RN) 1. Resident 9 was alert and standing by her bedside. Two eye drop solution bottles labeled as, Brimondine opthalmic 0.2% drops (eye drop medication to treat cataracts), and Dorsolamide ophthalmic drops 2 % (treat glaucoma) were observed on her bedside table. Resident 9 then took the two bottles of eye drop solution bottles and stated, these eyedrop bottles are mine. A concurrent interview was conducted with RN 1. RN 1 verified Resident 9 had two eyedrop solution bottles at bedside. RN 1 further stated there should be no medications left at the resident's bedside table. On September 9, 2019, Resident 9's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: On September 8, 2019, at 9:54 a.m., an observation was conducted with Resident 58. Multiple bluish and reddish skin discolorations observed on the resident's bilateral arms. In a concurrent interview, Resident 58 stated she did not remember when she had the skin discolorations on her bilateral forearm. Resident 58 further stated the nurses were aware of it. On September 8, 2019, at 10:15 a.m., an interview was conducted with Licensed Vocational Nurse (LVN) 3. LVN 3 stated due to Resident 58 old age in her 90's,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: On September 8, 2019, at 10:16 a.m., an observation with a concurrent interview was conducted with Resident 189. Resident 189 was in bed, alert, and conversant. Resident 189 stated she wore diapers (incontinence pads) and she did not use the bathroom for her B&B needs. Resident 189 further stated she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: On September 11, at 10:10 a.m., Resident 76's record was reviewed. The pharmacist's Monthly Medication Review (MRR) was reviewed with the acting director of nursing (ADON). Resident 76 was admitted to the facility on [DATE], with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly), bipolar (a mental disorder with episodes of mood swings), insomnia (inability to sleep), anxiety (excessive and persistent worry and fear about everyday situations) and depression (feelings of sadness and/or a loss of interest in activities). The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: 1a. On September 9, 2019, at 2:59 p.m., Resident 190's record was reviewed with Acting Director of Nursing (ADON). Resident 190 was admitted to the facility on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.