Premier Care Center For Palm Springs
PREMIER CARE CENTER FOR PALM SPRINGS in PALM SPRINGS, CA — inspection on August 20, 2025.
Found 3 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
Hypertensive episode. BP of 223/111.
Nurse Administered Clonidine.and Hydralazine (Both
evaluation . A review of Resident 1's Progress Notes, dated July 7, 2025, at 7:28 a.m., indicated
noted.A review of Resident 1's Progress Notes, dated July 23, 2025, at 6:42 a.m., indicated, .At 0600 (6 a.m.) BP was 198/95 gave patient evaluated BP medication PRN as ordered 15 mins (minutes) later recheck BP was 205/95 called 911.
Patient was sent out to (name of acute hospital) due to hypertension .Further review of Resident 1's record indicated there was no evaluation conducted or referral to the physician of Resident 1's elevated BP after readmitted from GACH on July 7, 2025, despite Resident 1's BP still above 160 almost daily. On July 24, 2025, at 2:03 p.m., an interview was conducted with the DON.
The DON stated the process to treat uncontrolled HTN included documenting a change of condition (COC), notification to the physician of COC, and follow-up monitoring of the resident's BP, documented every shift, for 72 hours.
The DON stated if a resident was transferred to GACH due to uncontrolled BP, he would expect the desk nurse to follow-up with the physician and communicate the resident's readmission, so the physician could re-evaluate the resident's HTN plan of care, and make adjustments as needed, including possible new medications and/or additional monitoring orders. In a concurrent review of Resident 1's record, the DON verified Resident 1 transferred to GACH for uncontrolled HTN, on July 6, 2025, and returned to the facility on July 7, 2025, at 7:28 a.m.
The DON verified he did not see documentation by the desk nurse that the physician was notified of resident's return from GACH on July 7, 2025.
The DON further stated the physician should have re-evaluated Resident 1 within a couple of days, of resident's return from GACH.
The DON stated if blood pressure medications were not effective, and the systolic blood pressure (top BP value) was still high, the resident had an increased risk of stroke.A review of the facility's policy and procedure titled, Significant Change in Condition, Response, revised January 2022, indicated, .It is the policy of this facility to ensure each resident receives quality of care and service to attain and maintain the highest practicable physical mental and psychosocial well-being .If, at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the License Nurse or Nurse Supervisor should be made aware.
Examples would be.Change or trending change in vital signs, to include.blood pressure.The Nurse will perform and document an assessment of the resident and identify need (sic) for additional interventions, considering implementation of existing orders or nursing interventions or through communication with the resident's provider (DR) using SBAR (COC) or similar process to obtain new orders or interventions.Nursing will provide no less than three (3) days of observation, documentation, and response to any interventions. An attempt to identify the cause for decline, when it occurs.nursing will be responsible for notifying the appropriate department for evaluation.
The nurse shall use his/her clinical judgment and shall contact the (DR) based on the urgent of the situation.
The Medical Director shall be notified in the event that the Attending Physician or on-call Physician cannot be reached.
The interdisciplinary team (IDT - a group of healthcare professionals) shall collaborate with the attending physician, resident, and/or resident representative to review risk indicators and the plan of care.
The IDT will document this collaboration.in the next scheduled Comprehensive Care Plan Meeting or sooner if deemed necessary by the IDT.
056328 08/20/2025
Premier Care Center for Palm Springs 2990 East Ramon Road Palm Springs, CA 92264
catheter. LVN 2 stated there should be a physician's order to remove an urinary catheter before
an interview was conducted with the DON, who stated he would expect the nurse who removed
blood in urine.
The DON verified there was no physician's orders to remove Resident 1's urinary catheter.
The DON stated he confirmed LVN 1 removed Resident 1's urinary catheter, and LVN 1 stated she did not document the removal of the resident's urinary catheter.
The DON stated staff are required to document every procedure. On July 24, 2025, at 2:03 p.m., a concurrent interview with the Director of Nursing (DON), and review of Resident 1's July Medication Administration Record (MAR), COC's, and monitoring notes was conducted.
The DON verified Resident 1 returned from GACH on July 7, 2025, with new orders from the physician for a bladder infection (UTI) and new medication orders were also written on July 11, 2025 for Rocephin (a medication to treat UTI).
The DON verified a COC and care plan for a UTI was not completed by nursing staff at the time, and should have been completed.
The DON stated, when a resident receives a foley catheter due to complaints of urinary retention, it was his expectations that nursing staff complete a COC and monitor the resident for signs and symptoms of adverse effects from the catheter, including urinary output, pain/discomfort & bladder distention, every shift for 72 hours.
The DON further stated, urinary output should be documented in the MAR, while other signs and symptoms of adverse effects from the catheter, should be documented in a monitoring note, each shift.
The DON stated he would expect a care plan to be developed for urinary retention and/or foley catheter to be initiated at the time of the complaint, or placement of the catheter.
The DON verified a care plan for Urinary Retention was not completed and should have been. A review of the facility's policy and procedure titled, Significant Change of Condition, revised January 2022, indicated, .If, at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should bed made aware.The nurse will perform and document an assessment of the resident and identify need for additional interventions, considering implementation of existing orders or nursing interventions.Nursing will provide no less than three (3) days of observation, documentation, and response to any interventions . A review of the facility's policy and procedure, Catheter, Indwelling Removal of, revised February 2025, indicated, .It is the policy of the facility that indwelling Foley catheters will be removed per (Dr's) order.PROCEDURES.Document all appropriate information in medical record.Document Procedure.
056328 08/20/2025
Premier Care Center for Palm Springs 2990 East Ramon Road Palm Springs, CA 92264
was conducted, which included the location of pain, for one out of three residents (Resident 1).This
2025, at 8:22 a.m., an unannounced visit to the facility was conducted to investigate a quality-of-care issue.On July 22, at 8:32 a.m., an interview was conducted with Resident 1, who stated she had a urinary catheter (a long tube insert into the bladder to drain urine) and the licensed nurse pulled it out (removed/discontinued it). Resident 1 stated she still had burning sensation when she urinated. Resident 1 stated Tylenol (acetaminophen - a non-steroidal anti-inflammatory medication to relieve pain) helps the irritation and discomfort (resident pointed towards her bladder).
Concurrently, Licensed Vocational Nurse (LVN) 1, asked Resident 1 what her pain rate was (on a scale from 1-10, 10 being the worst), and resident responded, 6 or 7.On July 22, 2025, at 8:47 a.m., an observation was made of LVN 1, returning to Resident 1's bedroom to administer Tylenol for bladder discomfort.A review of Resident 1's record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of Urinary Tract Infection (UTI - a bladder infection). A review of Resident 1's care plan (an individualized plan of care specific to a related problem, including time framed goals, and nursing interventions), initiated on June 9, 2025, which indicated, .Has acute pain (related to) disease process .Intervention to help relieve resident's pain .Monitor/document for probable cause of each pain episode.A review of Resident 1's physician's orders, dated June 22, 2025, indicated, .
Acetaminophen Extra Strength 500 mg (milligrams - a unit of measure), Give 2 (two) tablet (sic) by mouth every 4 (four) hours as needed for Severe Pain 7-10 (on pain scale) .A review of Resident 1's Medication Administration Record (MAR), for July 2025, indicated, Acetaminophen was administered to Resident 1 on July 22, 2025, at 8:45 a.m.A review of Resident 1's Progress Notes, dated July 22, 2025, at 8:45 a.m., by LVN 1, indicated Tylenol was administered to Resident 1 for a pain scale between 7-10.
There was no documentation of the location of the pain. A review of Resident 1's Progress Notes, dated, July 22, 2025, at 1:25 p.m., by LVN 2, indicated, . PRN Administration was: Effective.
Follow-up Pain Scale was: 5 .
Location of the pain not documented.On July 23, 2025, at 8:47 a.m., an interview was conducted with Registered Nurse (RN) 2, who stated the process to document administration of pain medications, includes documenting the medication administered, location of the pain, and effectiveness of the medication.On July 23, 2025, at 1:42 p.m., an interview was conducted, with LVN 1, who verified, on July 22, 2025, (at 8:45 a.m.) she administered acetaminophen to Resident 1 for discomfort from her urinary tract infection. LVN 1 further stated, when she monitors and documents administration of pain medications, she would include documenting the resident's pain rating on a scale of 1-10, the time the medication was given, and the location of the pain. LVN 1 stated when she administers a PRN pain medication, and she did not document the location in the progress notes, she would sometimes document under Condition Monitoring.A review of Resident 1's, Condition Monitoring, dated July 22, 2025, indicated there was no documentation of the pain location from LVN 1.On August 4, 2025, at 4:20 p.m., an interview was conducted with the Director of Nursing (DON), who stated he expected the nursing staff to assess a resident for pain, including the location prior to administration of the pain medication, and document the location in the progress note or condition monitoring.A review of the facility's policy and procedures titled, Medication Administration, revised December 2019, indicated, .When PRN (as needed) medications are administered, the following documentation is provided .Complaints or symptoms for which the medication was given .
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.