California Nursing & Rehabilitation Center
CALIFORNIA NURSING & REHABILITATION CENTER in PALM SPRINGS, CA — inspection on March 3, 2025.
Found 5 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
F-F692), kitchen and nutrition services (see findings under
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 .
056428
Form Approved OMB
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
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.
056428
Form Approved OMB
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
F-F908), and timely identification and repair of broken call light bell system (see findings under
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.
056428
Form Approved OMB
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